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Provider Policy Updates October 2026
Act
by Nov 1, 2026
Effective date
Nov 1, 2026
Identified
Oct 6, 2026
Summary
Select Health published October 2026 policy updates affecting coding, coverage, and documentation requirements across multiple clinical areas. Key changes include new time-based procedure codes and MUE policies (effective 8/21–8/27/2026), revised dental documentation audits (effective 11/1/2026), archived genetic testing policies, and eleven prospective coverage/exclusion changes effective 11/1/2026 for procedures including genetic sequencing, spinal fusion, kidney transplant, panniculectomy, and robotic-assisted surgeries. A prior authorization requirement for dental claims documentation takes effect 11/1/2026.
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What to do
by Nov 1, 2026 · 10 steps
01Billing team should implement prior authorization and documentation compliance for dental claims under Policy #D020, ensuring all claims include sufficient documentation in the member's dental record to verify service performed and level of care delivered, or claims will be denied.
02Update authorization protocols for Policy #141 (Kidney Transplant) and Policy #185 (Negative Pressure Wound Therapy) to require InterQual guidelines compliance; for kidney transplant, also accept recommendations from Optum Center of Excellence.
03Update authorization for Policy #622 (Spinal Fusion) to require InterQual guidelines compliance.
04Implement non-coverage edits in billing system for Policy #704 (Nidra—restless legs syndrome), Policy #698 (MARPE device), Policy #654 (Curonix PNS for knee osteoarthritis), Policy #514 (WGS/WES for solid tumors), Policy #570 (WGS/WES solid tumor tissue), and Policy #673 (ctDNA surveillance in Stage II colorectal cancer)—claims for these will be denied.
05Update coverage criteria for Policy #336 (Stereotactic Radiation Therapy) to include non-optimal surgical candidates with stages T1a and T1b.
06Shift patient responsibility for non-covered panniculectomy under Policy #463 exclusively to members (cosmetic classification).
07Coding team should review new policies CR-110 (Time-Based Procedure Codes) and CR-106 (MUE) effective 8/21 and 8/27/2026 respectively; verify whether practice has implemented these retrospectively.
08Update claims processing to reference Policy #123 (Gene Therapy, Testing, Counseling) instead of archived Policy #SH/GENETICS-A23.
09For all appeals, ensure submitted documentation is signed and the same signed documentation accompanies any appeal request.
10Affected plans: Commercial (unless summary text is bold, indicating broader applicability).
Original notice
Provider Policy Updates October 2026
selecthealth.org · Always check the source before changing claims.