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[Ohio] September 2026 Provider Newsletter
Effective date
Not stated in the notice
Identified
Sep 2, 2026
Summary
This September 2026 Ohio provider newsletter contains multiple policy updates affecting billing, prior authorization, reimbursement, and clinical guidelines across commercial, Medicare Advantage, and Medicaid plans. Key changes include new modifier requirements for E&M services (effective December 1, 2026 for Medicaid), laboratory service reimbursement policies for modifiers 90/91 (effective December 1, 2026), facility guidelines updates (effective December 1, 2026 for Commercial), and prior authorization requirement changes across multiple plan types.
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What to do
Action · 19 steps
01REQUIREMENTS:
By December 1, 2026: Billing team must implement multiple changes:
1.
02For Medicaid plans: Update billing software to require modifier 25 when billing eligible E&M services with XXX procedures.
03Train providers and billing staff on new modifier usage.
04Update encounter forms and EMR templates to remind providers to append modifier 25.
05Claims without appropriate modifier 25 will be denied.
062. For Medicare Advantage and Medicaid: Implement new combined reimbursement policy for modifiers 90 and 91 for laboratory services.
07Update fee schedules and billing system validation rules.
08Educate lab staff on modifier 90/91 usage requirements.
093. For Commercial plans: Update facility guidelines for claims related to professional services.
10Review current facility billing practices and adjust claim submission accordingly.
11System updates required in billing software.
12By October 1, 2026: Billing team must review and implement prior authorization requirement changes for Medicaid pharmacy (prior authorization and step therapy updates for medications billed under medical benefit).
13Update PA submission processes and provider notifications.
14By January 1, 2027: Implement new ordering, rendering, and prescribing (ORP) provider requirements for Medicaid/MyCare Ohio.
15Update credentialing files and provider records.
16Notify affected providers of new requirements.
17Immediate: Access Ohio Medicaid prior authorization request forms (Substance Use Disorder form, home healthcare/waiver services/private duty nursing authorization, perinatal risk assessment) from provider portal.
18Review Excludes1 notes effective October 1, 2026 for Commercial claims to ensure accurate coding and reduce denials.
19Review ASC claims guidance for Medicaid/MyCare Ohio to ensure CMS-1500 and UB-04 forms are correctly formatted.
Codes mentioned
259091
Original notice
[Ohio] September 2026 Provider Newsletter
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Virginia] September 2026 Provider NewsletterHighNo effective date · Newsletter[New York] September 2026 Provider NewsletterHighNo effective date · Newsletter[California] September 2026 Provider NewsletterHighNo effective date · Newsletter[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory ServicesHighEffective Dec 1, 2026 · Claims & BillingBrowse every Anthem BCBS change in the policy list