Policy Criteria Change - Material Amendment

By October 1, 2026: (1) Billing team must update billing system to reflect removed codes (81001-81015, 82542, 82677, 82947-82962, 83036, 83789, 86480-86804, 87077-87591, 87800-87850, G0472); these codes should reject or route to denial if submitted. (2) Update prenatal screening protocols to cover only: blood type/Rh determination at first visit and 24-28 weeks, CBC/hemoglobin-hematocrit, Group B strep screening (weeks 36-37), rubella antibody, varicella immunity testing, and fetal fibronectin (FFN) for preterm labor symptoms only; block billing for hCG testing and salivary hormone testing for routine pregnancy. (3) For CRP/ESR testing, implement condition-specific frequency limits in billing rules (e.g., arthritis: 1-3 months initially then 6-12 months; rheumatoid arthritis: prior to treatment, every 1-3 months during active disease, annually when inactive); deny claims for CRP/ESR without documented inflammatory diagnosis or during routine exams with normal findings. (4) Update encounter forms and provider education materials to reflect new criteria. (5) Notify OB-GYN and internal medicine providers of these changes and training on covered vs. non-covered scenarios. Failure to implement will result in claim denials and member complaints.