MedicaidCoverageHigh impact
Provider Notification - New Policy Updates - Clinical Payment, Coding, and Policy Changes Effective December 1, 2026
Aetna Better Health of Virginia·VA · Nephrology, Family Medicine, Internal Medicine +2 more·Reimbursement
Effective date
Dec 1, 2026
We identified it
Sep 26, 2026
Summary
Effective December 1, 2026, Aetna Better Health of Virginia is implementing new age-based eligibility requirements for specific CPT and HCPCS codes under VA Medicaid. Claims will be automatically denied if the member's age falls outside the specified ranges for ESRD dialysis codes (CPT 90957-90970), preventative care codes (CPT 99386-99397), and injectable medications (HCPCS J1307, J3387, J3391). Billing teams must verify member age before claim submission to avoid denials.
Action Required
By November 15, 2026: Billing team must implement age-verification checks in the billing system for all 17 affected codes. Update claim submission workflows to require documented member date of birth validation before processing. Modify encounter templates and billing software to flag or reject claims when: (1) CPT 90957-90959, 90965, 90969 submitted for members outside age 12-19; (2) CPT 90960-90962, 90966, 90970 submitted for members under age 20; (3) CPT 99386, 99396 submitted for members outside age 40-64; (4) CPT 99387, 99397 submitted for members under age 65; (5) HCPCS J1307 submitted for members under age 13; (6) HCPCS J3387 submitted for members outside age 4-17; (7) HCPCS J3391 submitted for members over age 17. Providers must verify member age at check-in and before coding. Communicate with clinical staff to ensure age-appropriate code selection. Any claims submitted outside these age ranges will be denied by Aetna Better Health of Virginia.