CommercialCoverageHigh impact
HealthPro News – October 2026
HMSA·HI·Provider News
Effective date
Jan 1, 2027
We identified it
Oct 4, 2026
Summary
HMSA is eliminating coverage for Transitional Care Management (TCM) codes 99495 and 99496 for commercial and QUEST members effective January 1, 2027, while maintaining coverage for Medicare members. Billing teams must transition to standard evaluation and management codes for post-discharge services on commercial and QUEST plans. Additionally, ASAM 3.5 residential treatment authorizations for QUEST members will change to initial 15-day authorizations with continued-stay reviews starting January 1, 2027.
Action Required
By December 31, 2026: Billing team must immediately update billing software to PROHIBIT CPT codes 99495 and 99496 for all commercial and QUEST member claims. Configure system to reject TCM codes with denial message directing providers to use standard E/M codes (99201-99215 or appropriate alternatives) instead. Update all encounter templates and billing instructions to remove TCM code guidance for commercial/QUEST. Medicare claims may continue using 99495/99496 per CMS guidelines only. Additionally, update authorization protocols for QUEST ASAM 3.5 admissions: change initial authorization length from current practice to 15 days maximum, with mandatory continued-stay reviews required thereafter. Configure system to auto-generate continued-stay review requests on day 15 for all QUEST ASAM 3.5 cases. Communicate changes to all providers via billing bulletins. Monitor January 2027 claims for TCM code violations on commercial/QUEST and immediately contact providers submitting invalid codes. Failure to comply will result in claim denials and revenue loss.