[New York] May 2026 Provider Newsletter

REQUIREMENTS - Multiple concurrent updates with staggered effective dates: 1. By July 1, 2026: Medicare Advantage - Billing team must update billing system to require modifier 25 on all XXX procedure claims when billed with an E&M service. Update encounter forms and provider education materials. Add validation rules to prevent submission without modifier 25. Claims missing modifier 25 will be denied. 2. By August 1, 2026: Commercial plans - Billing team must implement changes to specialty pharmacy policies and medical policy/clinical guideline updates. Review specialty pharmacy precertification list expansion. Update prior authorization requirements in billing system. Coordinate with providers on any documentation requirement changes. 3. By August 1, 2026: Medicaid - Billing team must implement reimbursement policy update for preventive medicine and sick visits on the same day. Update billing rules to reflect new payment methodology when both services are billed on same encounter. Test billing scenarios to ensure accurate claim submission. 4. By October 1, 2026: Commercial plans - Billing team must implement new prior authorization requirements for musculoskeletal procedures through Carelon Medical Benefits Management. Update system to require prior auth and train staff on submission process. Configure system alerts to prevent claim submission without prior auth authorization numbers. 5. Immediately: All staff - Refer to full policy documents at https://providernews.anthem.com/new-york/publications/may-2026-provider-newsletter-5506 for complete details on each update. Assign responsibility for system configuration changes by plan type.