Medicare AdvantagePrior AuthHigh impact
2026-09-10 - Indiana: $120M to Expand Maternal and Infant Health Services, Increase Primary Care Access & Grow the Health Care Workforce
Medicare/CMS·IN, MI, NY, RI·Quality Measures
Effective date
Oct 15, 2026
We identified it
Sep 10, 2026
Summary
This MLN Connects newsletter (Sept 10, 2026) contains multiple billing and compliance updates effective October 15, 2026, including: (1) DMEPOS prior authorization requirements for newly enrolled suppliers and change-of-ownership suppliers; (2) RHCs/FQHCs must bill telehealth services using individual CPT codes with modifiers 93 or 95 instead of G2025; (3) updated COVID-19 vaccine CPT codes and pricing; (4) EHR copy-forward documentation compliance requirements; and (5) revised Teaching Physician guidelines including new CPT 98016 and deletion of G2012.
Action Required
REQUIREMENTS:
By October 15, 2026:
- DMEPOS Suppliers: Billing team must implement prior authorization process for newly enrolled suppliers and suppliers undergoing change of ownership. Update billing software to require prior auth as condition of payment for specified DMEPOS items effective October 15. New/change-of-ownership suppliers must also ensure face-to-face encounter documentation and written orders are obtained prior to delivery. Failure to obtain prior authorization will result in claim denials.
- RHCs and FQHCs: Update billing system to discontinue use of HCPCS code G2025 for distant site telehealth services. Instead, bill individual CPT or HCPCS codes describing the specific service furnished with modifier 93 (audio-only telehealth) or modifier 95 (audio-video telehealth). Update encounter forms and provider training materials. Set payment rate at $97.53 for CY 2026 telehealth services.
- COVID-19 Vaccine Billing: Update billing software with new CPT codes (91304, 91319, 91320, 91321, 91322, 91323) and revised pricing allowances for 2026-2027 season. Providers must use crosswalk tool to identify corresponding National Drug Codes.
Immediately:
- All Providers: Review and correct EHR copy-forward practices. Do not rely solely on auto-populated patient information; verify all clinical documentation accurately reflects current visit assessment and decision-making. Ensure medical records are updated for current visit to prevent conflicting information and claim denials.
- Teaching Physicians: Update documentation templates to reflect guideline revision. Add CPT code 98016 (virtual check-in) to coding rules. Remove HCPCS code G2012 from billing systems. Implement virtual participation allowance for teaching physicians in all teaching settings.