CommercialCoverageHigh impact
Transitional Care Management Coverage Changing
HMSA·Coding
Effective date
Jan 1, 2027
We identified it
Oct 4, 2026
Summary
Effective January 1, 2027, HMSA will discontinue coverage of Transitional Care Management (TCM) codes 99495 and 99496 for commercial and QUEST (Medicaid) members. Providers must transition to standard evaluation and management codes for post-discharge services for these plan types, while Medicare members will continue to have TCM coverage available under CMS guidelines.
Action Required
By December 31, 2026: Billing team must update billing system to block submission of CPT 99495 and 99496 for all commercial and QUEST members effective January 1, 2027. Configure system to route post-discharge encounter claims for commercial/QUEST members to appropriate evaluation and management codes (e.g., 99213, 99214, 99215) or other clinically appropriate codes based on services documented. Providers must be notified to document post-discharge visits using standard E/M documentation requirements rather than TCM-specific requirements. Medicare claims may continue to use CPT 99495 and 99496 if CMS requirements are met. Test billing system changes in December 2026. Failure to implement changes will result in claim denials for commercial and QUEST members attempting to bill TCM codes on or after January 1, 2027.