What insurance policy changes affect Emergency Medicine providers?

Emergency Medicine providers face policy updates from major payers including prior authorization requirements, billing code changes, reimbursement rate adjustments, and coverage criteria revisions. PolicyChanges.app tracks these updates daily across all major insurers.

How often do insurance policies change for Emergency Medicine?

Insurance payers publish policy changes on rolling schedules: some quarterly, some monthly, and some with immediate effect. Emergency Medicine practices typically see dozens of relevant changes per year across their contracted payers.

How do I get notified of new Emergency Medicine policy changes?

Sign up for a free PolicyChanges.app account and create a saved search filtered to Emergency Medicine. You will get an email when new policy changes match your specialty filter: daily or weekly, your choice, on every plan.

Which payers post the most policy changes affecting Emergency Medicine?

Based on tracked changes, Emergency Medicine updates have come from payers including Anthem BCBS, Ambetter, Medi-Cal, Molina Healthcare.

PAYER POLICY CHANGES

Emergency Medicine Insurance Policy Changes

Keeping up with insurance policy changes that affect Emergency Medicine practices is a full-time job. This page aggregates the latest payer updates (prior authorization rule changes, reimbursement adjustments, billing code additions and removals, and coverage policy revisions) across all major insurers. Changes are identified and summarized daily so Emergency Medicine providers and their billing teams can act before deadlines pass.

Anthem BCBS · Effective Dec 1, 2026High impact
[California] Blood Product Administration services will no longer be billed separately
Effective December 1, 2026, Anthem Blue Cross Medi-Cal will no longer allow separate billing for Blood Product Administration services in Emergency Room, Clinic, and Treatment/Observation Room encounters. These services must now be included in the facility encounter reimbursement rather than billed as standalone line items. No change to benefits or covered services—only billing practice requirements are affected.
Ambetter · Effective Dec 6, 2026High impact
Leveling for Facility Claims
Ambetter from WellCare of Kentucky will apply national CPT guidelines to the coding of outpatient emergency department E&M levels for facility claims beginning 12/06/2026. Under the payer's comparative peer risk adjustment process, E&M claim lines will be recoded to the corrected level, with reimbursement at the highest level whose criteria are met, based on facility resources such as nursing time, clinical staff effort, supplies, equipment, and overhead rather than provider cognitive work. The payer's policy CC.PP.80 replaces the previous Optum EDC Analyzer.
Medi-Cal · Effective Jan 1, 2027High impact
FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027
Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status move from Medi-Cal managed care plans to Medi-Cal fee-for-service, so FQHC and RHC claims for these members must go directly to the Medi-Cal fiscal intermediary rather than to the former plan. Effective for services on or after January 1, 2027, claims sent to the former plan or to the FI for an MCP differential (wrap) rate will be denied, and from July 1, 2027, emergency and pregnancy-related services for these members are reimbursed only at the PPS rate with the appropriate diagnosis code and emergency indicator.
Molina Healthcare · Effective Jan 1, 2027High impact
10-30-2026 Reminder: Important information impacting claims payment for urgent care centers
Molina Healthcare of California requires all urgent care centers to submit a roster of rendering providers Previously due October 30, 2026 (date passed; verify current applicability) (a past deadline as of the analysis date). Starting January 1, 2027, claims must document the individual rendering provider instead of billing at the facility level only. Nurse Practitioners must include a supervising physician on the claim.
Molina Healthcare · Effective Jan 1, 2027High impact
10-16-2026 Important information impacting claims payment for urgent care centers
Molina Healthcare of California requires all urgent care centers to submit a roster of their providers by October 30, 2026, and quarterly thereafter. Effective January 1, 2027, urgent care centers must submit claims documenting the rendering provider instead of billing at the facility level. Nurse Practitioners must include a supervising physician on claims.
Anthem BCBS · Effective Feb 1, 2027High impact
[Georgia] New reimbursement policy: Inpatient Hospital Inclusive Services — Facility
Effective February 1, 2027, Anthem Blue Cross and Blue Shield in Georgia will no longer separately reimburse specific inpatient hospital services (including blood products, DME, nursing, pharmacy, therapy, radiology guidance, and professional services like catheter insertion and chemotherapy administration) when billed on the same date of service as an inpatient admission. Services must be reported correctly on CMS-1500/837P (professional) or UB-04 (facility) forms to avoid denial; balance billing members is prohibited.
Indiana Medicaid (IHCP) · Effective Nov 30, 2026Medium impact
BT2026185: IHCP updates Emergency Services Only billing requirements
Beginning November 30, 2026, the Indiana Health Coverage Programs (IHCP) requires all fee-for-service professional claims for Emergency Services Only (ESO) coverage to include an approved emergency or labor/delivery diagnosis in the primary position AND have the emergency indicator field marked on the claim for each service detail. This affects qualifying non-U.S. citizens enrolled in ESO Coverage with Pregnancy Coverage (Package B) or Emergency Services Only (Package E).
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective December 1, 2026, Carelon Medical Benefits Management is adding CPT code K0606 (Automatic external defibrillator, with integrated electrocardiogram analysis, garment type) to the precertification/prior authorization requirement for Anthem Blue Cross and Blue Shield commercial plans in Georgia. All orders for this device will now require prior authorization before service delivery.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Omnibus Codes
UnitedHealthcare's November 2026 Exchange bulletin, effective 2027-01-01, adds coverage language that several services (3D model creation from surface mesh files, CRISPR-based TB plasma/serum analysis, multianalyte Alzheimer/dementia lab tests, photobiomodulation for AMD, meibomian gland evaluation/evacuation incl. CPT 17999, histotripsy incl. CPT 1037T, and percutaneous gastrostomy with magnetic gastropexy) is unproven and not medically necessary, and revises criteria for irreversible electroporation, BeScreened-CRC, BIOTIA-ID, IVD CAPSULE PSP, external urine management systems (HCPCS E2001), noninvasive bimodal neuromodulation (E1399), and sacral Tarlov cyst surgery (63268, which now requires failure of conservative multidisciplinary management rather than 12 weeks of non-surgical treatment). Billing teams should hold these services for Exchange members as of 2027-01-01 and update charge entry and claim edits accordingly.
Medicare/CMS - Transmittals · Effective Jan 1, 2027Medium impact
R14017CP: January 2027 Annual Rural Emergency Hospital (REH) Monthly Facility Payment Amount
CMS has established the January 2027 monthly facility payment amount for Rural Emergency Hospitals (REHs) at $304,492.86 (after sequestration removal). Medicare Administrative Contractors must apply this updated payment amount to all REH providers effective January 1, 2027, with implementation by January 4, 2027.
Anthem BCBS · Effective Jan 1, 2027Medium impact
[Ohio] Precertification/prior authorization requirement changes
Effective January 1, 2027, Anthem Blue Cross and Blue Shield is adding precertification/prior authorization requirements for ambulance services (code A0999) for all Fully Integrated Dual Eligible (FIDE) plans in Ohio. Claims submitted without prior authorization for these services may be denied as ineligible for payment.
Illinois Medicaid - HFS · Effective Jan 1, 2027Medium impact
Government Owned Transportation Providers – Ground Emergency Medical Transportation (GEMT) – 2027 Participation
Government-owned ambulance providers in Illinois must submit updated cost reports and signed Intergovernmental Agreements (IGAs) by October 1, 2026 to participate in the Ground Emergency Medical Transportation (GEMT) supplemental payment program for calendar year 2027. Even providers currently participating in 2026 must resubmit; new participants must include signed IGAs from authorized local government officials.
Sentara Health Plans · Effective Feb 1, 2027Medium impact
Authorization Updates - Effective February 1, 2027
Effective February 1, 2027, Sentara Health Plans will require prior authorization for nine specific medical codes related to injectable/therapeutic joint procedures and ambulance services for all Commercial products in Virginia. Additionally, DMAS has already restricted coverage (effective October 13, 2026) of gender-affirming procedures for Medicaid and CHIP youth, though this does not change billing requirements—only coverage eligibility.
UnitedHealthcare · Effective Nov 1, 2026High impact
Ambulance Services (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky updated its ambulance services policy effective November 1, 2026, adding stricter documentation requirements, referencing Kentucky Administrative Regulations (KAR § 907-001-060) for medical necessity criteria, and introducing HCPCS code A0140. The policy now explicitly requires comprehensive medical record documentation (history, physical exam, diagnostic test results) to support medical necessity claims, and clarifies that documentation does not guarantee coverage.
Ambetter · Effective Nov 1, 2026High impact
Provider Notification: Cotiviti ED Leveling - Facility
Effective November 1, 2026, Ambetter Health will implement ED leveling for facility-based Emergency Department E&M services, applying national CPT billing guidelines to recede overcoded facility E&M levels. Facility E&M codes will be reimbursed based on resources utilized (nursing time, clinical staff, supplies, equipment) rather than physician cognitive work. This affects facility charges across Medicare, Marketplace, and Medicare-Medicaid plans.
Ambetter · Effective Nov 1, 2026High impact
Effective November 1, 2026, Ambetter Health will apply national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels.
Effective November 1, 2026, Ambetter Health will implement national CPT billing guidelines for emergency department E&M coding, focusing on facility resource utilization rather than provider cognitive work. The policy aims to reduce E&M overcoding by applying comparative peer risk adjustment to ensure claims are paid at the appropriate service level. Practices must align ED E&M coding with CMS and American College of Emergency Physicians guidelines emphasizing facility resources (nursing time, clinical staff effort, supplies, equipment, overhead).
Anthem BCBS · Effective Nov 1, 2026High impact
[Ohio] New reimbursement policy: Emergency Department: Leveling of Evaluation and Management Services
Anthem Ohio Medicaid is implementing a new ED E/M leveling policy effective November 1, 2026, that will validate submitted E/M code levels based on documented intensity and complexity of resources/interventions. Claims with E/M codes higher than supported by documentation will be subject to denial, resubmission requests, downward adjustment, or recovery of overpayments. Providers must ensure accurate E/M coding supported by comprehensive documentation of facility interventions.
Ambetter · Effective Oct 27, 2026High impact
Provider Notification: New Payment Policy: ED leveling for Facility Services (CC.PP.80)
Ambetter from MHS Indiana is implementing a new payment policy for ED (Emergency Department) leveling for facility services, effective October 27, 2026. Providers must review and validate their billing and coding workflows to align with this updated guidance to ensure compliance and consistent reimbursement for ED facility claims.
Blue Cross of Idaho · Effective Oct 1, 2026High impact
PAP312 - Sepsis Clinical Validation and Reimbursement - New
Blue Cross of Idaho has issued a new provider administrative policy (PAP312) establishing clinical validation and reimbursement standards for inpatient sepsis and septic shock claims effective October 2026. The policy requires hospitals to meet Sepsis-3 diagnostic criteria (including SOFA scoring) and specific documentation standards; claims not meeting these criteria will undergo pre- and post-payment review and may be reimbursed at lower DRG levels based on clinically supported diagnoses.
Nebraska Medicaid · Effective Oct 1, 2026High impact
Changes to Presumptive Eligibility Based on Immigration Status
Effective October 1, 2026, Nebraska Medicaid is restricting presumptive eligibility (PE) to individuals with eligible citizenship or immigration status (U.S. citizens, nationals, LPRs, Cuban-Haitian Entrants, and COFA migrants), with exceptions for pregnant women and children under 18 with valid legal status. PE providers must obtain attestation of eligibility status but are not required to verify documentation; applicants attesting to ineligible status must be denied PE.
Independence Blue Cross · Effective Oct 1, 2026High impact
07.02.21s, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
Independence Blue Cross updated ICD-10 diagnosis codes for AECG/MCOT monitoring policy effective 10/01/2026. Nine codes were terminated and replaced with more specific codes that better capture dilated cardiomyopathy subtypes, arrhythmogenic cardiomyopathy, and specific arrhythmia diagnoses including CPVT, Brugada syndrome, and ventricular bigeminy. Billing teams must update claim submission systems to use only the new codes to avoid claim denials.
Pennsylvania Medicaid (DHS) · Effective Oct 1, 2026High impact
MAB2026093002
Pennsylvania Medical Assistance (Medicaid) has updated hospital presumptive eligibility (PE) determination criteria effective October 1, 2026, to restrict federal Medicaid coverage for certain noncitizen groups. Refugees, asylees, humanitarian parolees, and other lawfully present individuals (except those under 21 or pregnant) are now ineligible for PE determinations. Acute care and psychiatric hospitals must immediately update their PE screening procedures to apply the new citizenship/immigration status criteria.
Medicare/CMS - Transmittals · Effective Oct 1, 2026High impact
R13978CP: October 2026 Update of the Hospital Outpatient Prospective Payment System (OPPS)
CMS is implementing the October 2026 Hospital Outpatient Prospective Payment System (OPPS) update, effective October 1, 2026 with implementation on October 5, 2026. The update adds 39 PLA codes (0660U through 0698U), 58 new Category III CPT codes, and new HCPCS codes, deletes HCPCS C8010 in favor of CPT 1091T, and sets new trauma activation billing rules using HCPCS G0390 with revenue code 068x.
Nevada Medicaid · Effective Oct 1, 2026High impact
Attention Hospital Presumptive Eligibility and Pregnancy Presumptive Eligibility Providers: Updated Immigration Rules for Hospital & Pregnancy Presumptive Eligibility (PE) Effective October 1, 2026
Effective October 1, 2026, Nevada Medicaid is restricting Hospital Presumptive Eligibility (PE) and Pregnancy PE eligibility based on federal immigration law changes (H.R.1 Section 71109). Only specific non-citizen groups—including LPRs meeting the 5-year bar, Cuban/Haitian entrants, COFA migrants, and those qualifying under CHIPRA 214—will remain eligible. Previously eligible groups (refugees, asylees, humanitarian parolees, TPS holders, trafficking victims, VAWA self-petitioners) will lose PE eligibility starting October 1, 2026, unless they qualify under alternative categories.
Ambetter · Effective Oct 1, 2026High impact
Important CC.PP.80 Policy Update
Arkansas Health & Wellness will begin applying national CPT billing guidelines for outpatient emergency department E&M codes effective October 1, 2026, focusing on facility resource utilization rather than provider complexity. The policy will recode claims to the appropriate E&M level based on resources used (nursing time, clinical staff, supplies, equipment) and allow reimbursement at the highest level for which criteria are met. This addresses CMS and OIG concerns about E&M overcoding in emergency departments.
Health Net · Effective Oct 1, 2026High impact
26-851 Definitive Drug Testing Billing Change, Effective October 1, 2026
Health Net will no longer reimburse CPT codes 80320-80377 for definitive drug testing effective October 1, 2026. Providers must transition to HCPCS G-series bundled laboratory codes (G0480-G0483) to avoid claim denials. All billing systems, charge masters, and workflows must be updated before the effective date.
BCBS Michigan · Effective Oct 1, 2026High impact
We’re making updates to the Emergency Department Facility Evaluation and Management coding policy
Blue Cross Blue Shield of Michigan is expanding prepayment review of emergency department claims to include E/M levels 2-5 (previously only levels 4-5 were reviewed) effective October 1, 2026. Claims not meeting policy criteria will be automatically adjusted downward to the appropriate level. Fee-schedule hospitals will see automatic adjustments; percent-of-charge hospitals must resubmit adjusted claims for payment.
Florida Blue · Effective Oct 1, 2026High impact
COVID-19 Laboratory Tests Reimbursement Changes for Urgent Care Centers and Convenience Care Clinics
Effective October 1, 2026, Florida Blue will no longer provide separate reimbursement for COVID-19 laboratory tests performed at Urgent Care Centers (UCC) and Convenience Care Clinics (CCC). COVID-19 lab testing reimbursement will be bundled into the standard urgent care service fee, similar to flu and strep tests. Billing teams must stop billing 15 specific COVID-19 lab procedure codes for separate reimbursement at these locations.
Anthem BCBS · Effective Oct 1, 2026High impact
[California] Critical Care to Home: what care providers need to know
Effective October 1, 2026, Anthem Blue Cross Medi-Cal will no longer reimburse Critical Care services (CPT 99291, 99292) billed with revenue code 045X when the member is discharged home. This change redefines Critical Care eligibility based on discharge status, requiring billing teams to identify and deny or redirect these claims. Trauma and Observation services remain reimbursable.
Arkansas Blue Cross Blue Shield · Effective Oct 1, 2026High impact
Drug Policy Criteria Change
New criteria and limits have been added for Tapentadol ER formulary coverage, and a 7-day duration limit with MME (Morphine Milligram Equivalent) limits has been implemented for immediate-release opioids in acute pain treatment. These changes affect the Metallic formulary tier and update opioid prescribing guidelines.
Ambetter · Effective Sep 29, 2026High impact
New Payment Policy: Leveling of Care: ED E/M Overcoding for Professional Services (CC.PP.076) & Office-based E/M Overcoding (CC.PP.066)
Managed Health Services (MHS Indiana) is implementing a new payment policy effective 9/29/2026 to address E/M overcoding in emergency department and office-based settings. Providers must review and validate that their billing and coding workflows align with the updated guidance to ensure compliant claims processing and accurate reimbursement under Medicare and Marketplace plans.
Ambetter · Effective Sep 28, 2026High impact
Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services
Effective September 28, 2026, Ambetter of North Carolina will implement automated recoding of emergency department E&M facility service claims to appropriate CPT levels based on resources utilized (nursing time, clinical staff, supplies, equipment, overhead), not physician cognitive work. Claims billed at higher levels than supported by facility resources will be automatically downleveled to the highest level meeting criteria under their peer risk adjustment process.
Ambetter · Effective Sep 15, 2026High impact
Emergency Department Facility E/M Leveling Update (PDF)
Home State Health is transitioning ED facility E/M leveling from Optum (Policy CC.PP.064) to Cotiviti (Policy CC.PP.80), effective September 15, 2026. The new vendor will conduct pre-payment clinical review with a Level 3 payment floor, ensuring claims are not reduced below CPT 99283/G0382. This enhances transparency and CMS alignment but does not introduce new denials or remove appeal rights.
Ambetter · Effective Sep 1, 2026High impact
Optum Payment Integrity - Editing Area: Effective September 1, 2026
Effective September 1, 2026, Sunflower Health Plan (through Optum) is implementing eight new prepayment claim review editing areas targeting specific billing patterns across Medicare, Marketplace, and Commercial plans. Providers will experience increased requests for medical record submission prior to payment; claims without timely documentation submission will be denied. The editing areas focus on trauma activation coding, high-dollar hardware/lab claims, surgical code cross-matching, EEG coding, incision/drainage procedures, and selective catheter placement.
Ambetter · Effective Sep 1, 2026High impact
Effective September 1, 2026: Revised Payment Policy- Leveling of Care: Emergency Department Evaluation and Management Over-coding for Facility Services
Superior HealthPlan is replacing its emergency department leveling policy (CC.PP.064) with a new policy (CC.PP.80) effective September 1, 2026, that will conduct post-claim reviews of facility-reported ED E/M levels for consistency with documented resources (labs, imaging, procedures, treatments). Claims with E/M levels not supported by documented resources will be downleveled to the appropriate level, potentially reducing reimbursement. Critical care CPT codes (99291, 99292) may exclude facility claims from this review.
Ambetter · Effective Sep 1, 2026High impact
Concert Genetics Policies
Ambetter Health is implementing seven new Concert Genetics policies effective September 1, 2026, establishing clinical and payment criteria for infectious disease lab testing across multiple categories (respiratory, multi-system, dermatologic, gastroenterologic, preventive screening, vector-borne, and genitourinary). A new laboratory payment policy (CG.CC.PP.01) outlines correct coding requirements for lab and molecular testing. Billing teams must obtain and review the full policy text to identify specific coding impacts and prior authorization requirements.
Anthem BCBS · Effective Sep 1, 2026High impact
[Georgia] Observation service billing: review CMS requirements before
Effective September 1, 2026, Anthem Blue Cross and Blue Shield (Georgia) is updating observation service billing requirements to align with CMS guidance for claims billed under POS codes 19, 22, or 23. Key restrictions include: only one initial observation service code per patient visit, one observation code per calendar date per billing practitioner, and only the ordering/overseeing physician may bill observation codes—other practitioners must use appropriate outpatient service codes instead.
Anthem BCBS · Effective Sep 1, 2026High impact
[New York] Observation service billing: review CMS requirements before
Effective September 1, 2026, Anthem Medicare Advantage in New York is updating observation service billing requirements to align with CMS guidance for POS codes 19, 22, and 23. Key changes: only one initial observation service code per patient visit, only one observation code per calendar date per billing practitioner, and only the ordering/overseeing physician may bill observation codes—consultants must use appropriate outpatient service codes instead.
Texas Medicaid · Effective Sep 1, 2026High impact
Reimbursement Rate Updates for Ambulance Procedure Codes Effective September 1, 2026
Texas Medicaid (TMHP) is implementing reimbursement rate changes for ambulance procedure codes effective September 1, 2026. Specific rate updates are contained in a linked spreadsheet that must be reviewed and integrated into billing systems. The policy also clarifies that MCOs may have different prior authorization and administrative requirements than traditional Medicaid.
Humana · Effective Aug 26, 2026High impact
Crisis Stabilization for Adults - MEDICAID - LOUISIANA (Revised)
This is a revised Louisiana Medicaid policy for Crisis Stabilization (CS) services for adults, effective 08/26/2026. The policy establishes coverage criteria, assessment requirements, intervention standards, and care coordination protocols for short-term bed-based crisis mental health treatment. Key billing requirement: Concurrent review is mandatory after the initial 24-hour period, and claims may be subject to recoupment if documentation does not support medical necessity of the crisis.
CareSource · Effective Aug 13, 2026High impact
[Ohio] Appropriate Billing of Services
CareSource (Ohio Medicaid & MyCare) is enforcing 12 specific billing compliance initiatives aligned with Ohio Administrative Code rules, effective August 13, 2026. Providers must immediately audit billing practices for dialysis frequency limits, post-operative E&M bundling, incontinence supply limits, inpatient service bundling, sedation bundling, observation unit caps, readmission consolidation, behavioral health same-day restrictions, hospice/NF overlap denials, HCBS/institutional overlap denials, and OTP unit limits. Non-compliance will result in claim denials and payment interruptions.
Michigan Medicaid - MDHHS · Effective Aug 1, 2026High impact
MMP 26-24: Hospital 15-Day Readmissions
Effective August 1, 2026, Michigan Medicaid modifies hospital reimbursement for 15-day readmissions. Readmissions within 15 days to a DIFFERENT hospital for the SAME condition now receive full payment to both hospitals (previously considered part of a single episode). Readmissions to the SAME hospital for a related condition remain part of a single episode; unrelated conditions are always separate episodes regardless of hospital. This policy is contingent on CMS State Plan Amendment approval.
Ambetter · Effective Aug 1, 2026High impact
Update for Procedure Codes S9083 and S9088: Effective 8/1/2026
Effective August 1, 2026, procedure codes S9083 and S9088 become reimbursable ONLY when billed with place of service 20 (urgent care facilities). Claims submitted with any other place of service will be denied. S9083 represents a global urgent care facility service, while S9088 is an add-on code for urgent care operational costs that must accompany an E/M or procedure code.
BCBS Oklahoma · Effective Jul 15, 2026High impact
New Claims Editing Rules To Be Implemented in July 2026
New claims editing rules will be implemented in July 2026 affecting multiple procedure codes and billing scenarios. These automated edits will result in claim denials or payment adjustments for various issues including missing modifiers, incorrect diagnosis sequencing, and inappropriate code combinations.
BCBS Montana · Effective Jul 15, 2026High impact
New Claims Editing Rules To Be Implemented in July 2026
Blue Cross Blue Shield of Montana is implementing 18 new automated claims editing rules in their Lyric software database effective July 15, 2026. These rules will automatically deny or rebundle claims that don't meet specific coding requirements, with denials showing reason codes beginning with 'G'.
BCBS New Mexico · Effective Jul 15, 2026High impact
New Claims Editing Rules To Be Implemented in July 2026
Blue Cross Blue Shield of New Mexico is implementing comprehensive claims editing rules in July 2026 that will automatically deny or rebundle claims with coding errors, affecting radiation therapy, STI testing, colonoscopies, hospital services, and many other procedures. Claims receiving edits will show ineligible reason codes starting with 'G'.
BCBS Illinois · Effective Jul 15, 2026High impact
New Claims Editing Rules To Be Implemented in July 2026
Blue Cross Blue Shield of Illinois will implement 18 new claims editing rules in July 2026 that will automatically deny or rebundle claims with specific coding errors, including radiation therapy planning, STI testing combinations, colonoscopy injections, and missing modifiers. Claims receiving these edits will show reason codes with 'G' alpha characters.
BCBS Texas · Effective Jul 15, 2026High impact
New Claims Editing Rules To Be Implemented in July 2026
Blue Cross Blue Shield of Texas is implementing new claims editing rules in July 2026 that will automatically deny or rebundle claims for various coding scenarios. Claims receiving these edits will show ineligible reason codes with an alpha character 'G' and affect multiple specialties including radiation therapy, STI testing, colonoscopy procedures, and hospital billing.
Providence Health Plan · Effective Jul 1, 2026High impact
Special Alert May 2026 - Optum Emergency Department Claim Analyzer
Effective July 1, 2026, Providence Health Plan will implement the Optum Emergency Department Claim (EDC) Analyzer to evaluate ED facility claims for Commercial and Medicare lines of business. The analyzer will review ED claims with CPT codes 99283, 99284, or 99285 to ensure billed service levels align with documented intensity, services, and patient complexity. Claims not supported by documentation may be adjusted to the appropriate level or denied.
Harvard Pilgrim Health Care · Effective Jul 1, 2026High impact
Point32Health Payment Policy updates
Point32Health issued multiple payment policy updates effective 7/1/2026 affecting eight service categories across Harvard Pilgrim and Tufts Health plans. Most updates are minor administrative clarifications, but two require immediate billing changes: (1) Behavioral Health now prohibits billing psychological test codes (96130-96131) and neuropsychological test codes (96132-96133) together in the same episode of care—providers must select only the predominant service code; (2) Obstetrics/Gynecology (Tufts Health RITogether only) now allows doula service billing using specific HCPCS codes (S9445, S9446, 59510, 59400) with modifiers instead of S9445 alone.

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[California] Blood Product Administration services will no longer be billed separately

Leveling for Facility Claims

FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027

10-30-2026 Reminder: Important information impacting claims payment for urgent care centers

10-16-2026 Important information impacting claims payment for urgent care centers

[Georgia] New reimbursement policy: Inpatient Hospital Inclusive Services — Facility

BT2026185: IHCP updates Emergency Services Only billing requirements

[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

Omnibus Codes

R14017CP: January 2027 Annual Rural Emergency Hospital (REH) Monthly Facility Payment Amount

[Ohio] Precertification/prior authorization requirement changes

Government Owned Transportation Providers – Ground Emergency Medical Transportation (GEMT) – 2027 Participation

Authorization Updates - Effective February 1, 2027

Ambulance Services (for Kentucky Only)

Provider Notification: Cotiviti ED Leveling - Facility

Effective November 1, 2026, Ambetter Health will apply national CPT billing guidelines for the appropriate coding of outpatient emergency department Evaluation and Management (E&M) code levels.

[Ohio] New reimbursement policy: Emergency Department: Leveling of Evaluation and Management Services

Provider Notification: New Payment Policy: ED leveling for Facility Services (CC.PP.80)

PAP312 - Sepsis Clinical Validation and Reimbursement - New

Changes to Presumptive Eligibility Based on Immigration Status

07.02.21s, Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring

MAB2026093002

R13978CP: October 2026 Update of the Hospital Outpatient Prospective Payment System (OPPS)

Attention Hospital Presumptive Eligibility and Pregnancy Presumptive Eligibility Providers: Updated Immigration Rules for Hospital & Pregnancy Presumptive Eligibility (PE) Effective October 1, 2026

Important CC.PP.80 Policy Update

26-851 Definitive Drug Testing Billing Change, Effective October 1, 2026

We’re making updates to the Emergency Department Facility Evaluation and Management coding policy

COVID-19 Laboratory Tests Reimbursement Changes for Urgent Care Centers and Convenience Care Clinics

[California] Critical Care to Home: what care providers need to know

Drug Policy Criteria Change

New Payment Policy: Leveling of Care: ED E/M Overcoding for Professional Services (CC.PP.076) & Office-based E/M Overcoding (CC.PP.066)

Leveling of Care: Emergency Department Evaluation and Management Overcoding for Facility Services

Emergency Department Facility E/M Leveling Update (PDF)

Optum Payment Integrity - Editing Area: Effective September 1, 2026

Effective September 1, 2026: Revised Payment Policy- Leveling of Care: Emergency Department Evaluation and Management Over-coding for Facility Services

Concert Genetics Policies

[Georgia] Observation service billing: review CMS requirements before

[New York] Observation service billing: review CMS requirements before

Reimbursement Rate Updates for Ambulance Procedure Codes Effective September 1, 2026

Crisis Stabilization for Adults - MEDICAID - LOUISIANA (Revised)

[Ohio] Appropriate Billing of Services

MMP 26-24: Hospital 15-Day Readmissions

Update for Procedure Codes S9083 and S9088: Effective 8/1/2026

New Claims Editing Rules To Be Implemented in July 2026

New Claims Editing Rules To Be Implemented in July 2026

New Claims Editing Rules To Be Implemented in July 2026

New Claims Editing Rules To Be Implemented in July 2026

New Claims Editing Rules To Be Implemented in July 2026

Special Alert May 2026 - Optum Emergency Department Claim Analyzer

Point32Health Payment Policy updates