What insurance policy changes affect General Practice providers?

General Practice 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 General Practice?

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

How do I get notified of new General Practice policy changes?

Sign up for a free PolicyChanges.app account and create a saved search filtered to General Practice. 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 General Practice?

Based on tracked changes, General Practice updates have come from payers including Michigan Medicaid - MDHHS, SC Medicaid - SCDHHS, HMSA, UnitedHealthcare.

PAYER POLICY CHANGES

General Practice Insurance Policy Changes

Keeping up with insurance policy changes that affect General Practice 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 General Practice providers and their billing teams can act before deadlines pass.

Michigan Medicaid - MDHHS · Effective Dec 1, 2026High impact
MMP 26-47: Maternal Infant Health Program Rate Increase and Update to Care Coordination Requirements
Effective December 1, 2026, Michigan Medicaid will increase reimbursement rates for Maternal Infant Health Program (MIHP) services (HCPCS codes H1000, H2000, T1023, T2022) and update care coordination requirements. The minimum time threshold for billable care coordination services increases from 30 minutes to 60 minutes per calendar month, and documentation must now include start/end times and detailed activity descriptions signed by an LSW or RN.
SC Medicaid - SCDHHS · Effective Dec 1, 2026High impact
Updates to the Durable Medical Equipment Services Manual
South Carolina SCDHHS is updating its Durable Medical Equipment (DME) Services Manual and DME Fee Schedule, effective December 1, 2026. The updates will clarify covered services and clinical criteria, update documentation and medical necessity requirements, specify face-to-face encounter requirements, provide updated billing guidance, and define units, frequencies, and authorization requirements for procedure codes. Providers must review the draft manual and submit feedback by November 2, 2026, and attend training webinars on November 10 or December 3, 2026.
HMSA · Effective Dec 1, 2026High impact
HealthPro News – October 2026
HMSA's October 2026 provider newsletter, issued Oct. 1, 2026, lists several changes with different dates. Effective Jan. 1, 2027, HMSA will no longer cover Transitional Care Management (TCM) codes 99495 and 99496 for commercial and QUEST members, while TCM remains a covered benefit for Medicare members when CMS requirements are met. Effective Dec. 1, 2026, commercial plans will require blood and blood products to be billed with Revenue Code 038X and the applicable HCPCS code, and blood processing and storage services with Revenue Code 039X.
UnitedHealthcare · Effective Dec 1, 2026High impact
Cardiovascular Disease Risk Tests (for New Mexico Only)
UnitedHealthcare Community Plan of New Mexico (Medicaid) is revising its cardiovascular disease risk testing policy effective December 1, 2026. The policy narrows coverage by removing lipoprotein(a) testing from the unproven list (making it potentially coverable) while adding noninvasive point-of-care cardiac platforms like CorVista System to the non-covered list, and updating applicable CPT codes with a new quarterly edit code (1104T) and removal of code 83695.
UnitedHealthcare · Effective Dec 1, 2026High impact
Breast Imaging for Screening and Diagnosing Cancer (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its breast imaging policy effective December 1, 2026, clarifying coverage criteria for MRI breast screening in high-risk individuals while designating several advanced imaging modalities (including Molecular Breast Imaging for routine screening and Positron Emission Mammography) as unproven and not medically necessary. The policy removed the standalone BSGI definition and refined language around MRI indications, genetic risk criteria, and age thresholds for screening initiation.
CareSource · Effective Dec 1, 2026High impact
[Ohio] Avalon Policy Updates
CareSource Ohio Medicaid has partnered with Avalon Healthcare Solutions for laboratory benefits management and is revising 36 laboratory reimbursement policies effective December 1, 2026. These revised policies govern routine lab testing through Avalon's post-service pre-payment clinical claim editing program (RTM). No prior authorization requirement changes are indicated, but billing teams must ensure compliance with updated lab policies on Avalon's website to avoid claim denials.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claim forms. These services are only reimbursable when submitted by the rendering provider on CMS-1500 professional claim forms using the applicable codes. Participating providers cannot balance bill members for this change.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claims. These services are now eligible for reimbursement ONLY when submitted by the rendering provider on CMS-1500 (professional claim form). Billing teams must route these services to the correct claim form type to avoid denials.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) effective December 1, 2026, that prohibits pass-through laboratory billing with modifier 90 on professional and outpatient facility claims—these claims will no longer be reimbursed. Providers performing lab tests must bill directly. Modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and eligible for reimbursement. The previous modifier 91 policy (G-06020) will be retired.
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 (facility claims). These services are now eligible for reimbursement ONLY when submitted on CMS-1500 (professional claim form) by the rendering provider. Billing teams must immediately audit billing workflows to prevent claim denials and ensure correct claim form submission.
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.
NC Medicaid - NCDHHS · Effective Dec 31, 2026High impact
NC Integrated Care for Kids Closeout and Related Billing Code Changes
NC Medicaid is closing the NC Integrated Care for Kids (InCK) pilot program effective December 2026. Two food/housing screening G codes (G9919, G9920) will be rejected after December 31, 2026, while the Kindergarten Readiness Promotion Bundle code (CPT 1003F with modifiers SE, TS) will continue indefinitely for well-child visits in children ages birth to 6. Billing teams must stop using the discontinued G codes and ensure proper use of CPT 1003F with appropriate modifiers to document bundle completion.
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.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] 2027 Medicare formulary changes: Prepare now for
Effective January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Ohio will move 10 select medications to nonformulary status, including common drugs for asthma, COPD, diabetes, anticoagulation, and inflammatory conditions. The practice must review patient medication lists, coordinate therapy transitions to covered alternatives before the effective date, and submit pharmacy prior authorizations electronically to avoid claim denials and treatment delays in January.
Nebraska Medicaid · Effective Jan 1, 2027High impact
Targeted Case Management Program for Chronic Diseases (TCMP CD) - LB 527
Nebraska Medicaid is implementing a new Targeted Case Management Program for Chronic Diseases (TCMP CD) effective January 1, 2027, paying qualified PCMH-certified providers $75 per member per month for managing beneficiaries with diabetes and chronic kidney disease stage 3 or higher. Providers must enroll as a new PCMH provider type by March 31, 2027, and may submit backdated claims for services provided January 1–March 31, 2027, if filed by October 31, 2027.
Highmark · Effective Jan 1, 2027High impact
ValueBlue Partial Capitation Reimbursement Begins Jan. 1, 2027
Highmark ValueBlue introduces a partial capitation reimbursement model for primary care providers (PCPs) effective January 1, 2027. PCPs must enroll by December 1, 2026, to participate; those who do not enroll will face a 20% reduction in capitated codes on the community fee schedule effective April 1, 2027.
Michigan Medicaid - MDHHS · Effective Jan 1, 2027High impact
MMP 26-46: Updates to Coverage of Maternity Care Services
Effective January 1, 2027, Michigan Medicaid transitions from global maternity CPT codes (59400, 59510, 59620, 59425, 59426, 59430) to separate encounter-based E/M and obstetric procedure codes. Providers must append modifier TH and appropriate ICD-10-CM diagnosis codes to routine antepartum and postpartum E/M claims to qualify for enhanced reimbursement. Claims submitted with global codes on/after January 1, 2027 will only be paid if all service dates occurred by December 31, 2026.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027High impact
BT2026182: COVID-19 vaccine administration to no longer be carved out of managed care
Effective January 1, 2027, COVID-19 vaccine administration services transition from carved-out status to managed care for HIP, Hoosier Healthwise, Hoosier Care Connect, and Indiana PathWays members. Claims for COVID-19 vaccines and administration with service dates on or after 2027-01-01 must be submitted to the member's MCO instead of fee-for-service. FQHCs and RHCs remain carved out and continue submitting to FFS processors.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027High impact
BT2026171: IHCP corrects claim processing for FQHC and RHC encounter billing of codes T1015 and D9999
The Indiana Health Coverage Programs (IHCP) is implementing a systematic validation correction for FQHC and RHC claims effective January 1, 2027. Starting on this date, the FFS claim-processing system will require that every T1015 (medical encounter) or D9999 (dental encounter) code billed for a specific date of service must be accompanied by at least one valid encounter code from the IHCP-approved Myers and Stauffer Annual Encounter Code Listings for that same date. T1015 or D9999 details without a corresponding valid encounter code will be denied with no reimbursement. This corrects a previous processing gap where some multi-DOS claims were not being validated against this existing requirement.
Ambetter · Effective Jan 1, 2027High impact
Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective 01/01/2027, Ambetter Health will discontinue coverage for 45 HCPC H codes (primarily behavioral health and community support services) and will begin covering HCPC code H0006. Billing teams must update coding practices and prior authorization workflows to reflect these coverage changes.
MassHealth · Effective Jan 1, 2027High impact
All Provider Bulletin 421: Enrollment Requirement for All Providers on Claims Submitted to MassHealth - Corrected
Effective January 1, 2027, MassHealth will require all ordering, referring, prescribing, attending, supervising, and operating (ORPASO) providers on claims to be enrolled with MassHealth on the date of service (or within 90 days after first date of service for ordered/referred/prescribed services). Claims with unenrolled providers in these roles will be denied. MassHealth is currently sending informational denial messages to prepare providers for this enforcement.
Humana · Effective Jan 1, 2027High impact
Januvia (sitagliptin) (New)
Humana has implemented a NEW prior authorization policy for Januvia (sitagliptin) effective January 1, 2027, for Medicare Advantage members with type 2 diabetes. Coverage requires members to have tried or be unable to use generic sitagliptin first, and prior authorization is mandatory for all brand-name Januvia prescriptions.
Humana · Effective Jan 1, 2027High impact
Janumet (sitagliptin and metformin hydrochloride) (New)
Humana Medicare Advantage has implemented a new prior authorization requirement for Janumet (sitagliptin/metformin) effective January 1, 2027. Coverage requires patients to have type 2 diabetes and either tried or be unable to use generic sitagliptin/metformin, with a critical exclusion: patients with a history of pancreatitis are not eligible. This is a brand-to-generic step therapy policy.
UnitedHealthcare · Effective Jan 1, 2027High impact
Michigan: The MCT2D CGM prior auth bypass will end on Jan. 1
UnitedHealthcare's prior authorization bypass pilot program for continuous glucose monitors (CGM) in type 2 diabetes patients ends January 1, 2027. After this date, CGM prescriptions will require standard prior authorization and must meet UnitedHealthcare's coverage criteria. Members prescribed CGM on or before December 31, 2026, will retain bypass status for 12 months or until December 31, 2027, whichever comes first.
Humana · Effective Jan 1, 2027High impact
DPP-IV, SGLT2 Combination Products (New)
Humana Medicare Advantage has implemented a new prior authorization policy for DPP-IV/SGLT2 combination diabetes medications (Steglujan, Qtern, Glyxambi, dapagliflozin-saxagliptin). Effective January 1, 2027, all claims for these products require prior authorization and must meet two criteria: Type 2 Diabetes Mellitus diagnosis AND documented trial or contraindication to a single DPP-4 inhibitor (sitagliptin or linagliptin) OR a single SGLT2 inhibitor (empagliflozin or dapagliflozin). Approvals are granted for plan year durations or as determined through clinical review.
Highmark · Effective Jan 1, 2027High impact
Evolving Primary Care Reimbursement in 2027: Introducing ValueBlue and ValueBlue Connect
Highmark is replacing its current PCP fee-for-service and True Performance programs with two new value-based models effective January 1, 2027: ValueBlue (partial capitation with monthly payments for attributed members plus fee-for-service for preventive/wellness services) and ValueBlue Connect (incentive program rewarding quality outcomes and care coordination). This fundamentally changes how primary care providers are reimbursed, shifting from visit-based billing to population health management with stable monthly payments.
Ambetter · Effective Jan 1, 2027High impact
Ambetter of Tennessee Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter of Tennessee will discontinue coverage for 46 HCPCS H codes (primarily behavioral health and social services codes) while adding coverage for H0006. The billing team must identify all claims currently using the non-covered codes and transition to alternative billing codes or obtain clarification on approved alternatives before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Absolute Total Care Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Absolute Total Care will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims using discontinued codes and transition to alternative codes or obtain patient verification of coverage changes.
Ambetter · Effective Jan 1, 2027High impact
Ambetter of North Carolina Inc. Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter of North Carolina Inc. will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must immediately identify affected claims and update billing systems to prevent denials for these services beginning 2027.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Louisiana Healthcare Connections Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Louisiana Healthcare Connections will discontinue coverage for 45 HCPCS H codes (behavioral health and social services) while adding coverage for H0006. Billing teams must identify affected claims, update system edits, and establish alternative coding or prior authorization protocols before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from WellCare of Kentucky Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from WellCare of Kentucky will discontinue coverage for 46 HCPCS H codes (behavioral health and social services codes), while simultaneously activating coverage for H0006. Billing teams must identify all claims currently using the discontinued codes and establish alternative billing strategies or obtain prior authorization requirements before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Peach State Health Plan Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Peach State Health Plan will discontinue coverage for 45 HCPC H codes (H0003-H0047, H1011, H2001-H2033) commonly used for behavioral health, substance abuse treatment, and support services. Simultaneously, H0006 coverage will be newly activated. Practices must identify affected claims, update billing systems, and establish alternative coding or coverage verification processes before the effective date.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Sunflower Health Plan Billing Code Update for various HCPC H Codes Effective 01/01/2027
Effective January 1, 2027, Ambetter from Sunflower Health Plan will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must identify all claims currently using discontinued codes and establish alternative billing strategies or obtain patient notification protocols before the effective date.
Florida Blue · Effective Jan 1, 2027High impact
Maternity Care Services Global CPT Code Changes
Effective January 1, 2027, Florida Blue and Truli for Health are eliminating global obstetric bundles and transitioning to itemized billing for maternity care. Prenatal visits, labor management, delivery, and postpartum care will be billed separately using new CPT codes (12 new codes added, 6 revised, 17 removed). Billing teams must update coding workflows, EHR configurations, and documentation practices to reflect E&M codes for prenatal/postpartum care and new labor management codes by the effective date.
NC Medicaid - NCDHHS · Effective Jan 1, 2027High impact
Transition to American Medical Association Maternity Current Procedural Terminology 2027 Code Changes Effective Jan. 1, 2027
NC Medicaid is transitioning to new AMA maternity CPT codes effective January 1, 2027. Starting September 1, 2026, providers must begin using E/M codes (99202-99215) with the TH modifier for prenatal/postpartum care when delivery is anticipated after 1/1/2027. All current maternity codes including global bundles will be deleted on 1/1/2027. Current codes may be used through 12/31/2026 for pregnancies completing before that date.
Connecticut Medicaid (HUSKY Health) · Effective Nov 11, 2026Medium impact
DSS Important Message - Hospital Monthly Important Message - 10.19.2026
Connecticut's Department of Social Services posted its hospital important message for Medicaid (CMAP) providers, updated 10/19/2026, covering several changes with different dates. Some are already in effect as of today, including the October 1, 2026 ICD-10 and HCPCS updates and the October 13, 2026 diagnosis code requirement for gender-affirming care, while the Addendum B and new, changed or deleted procedure code updates and the new 3M grouper are scheduled for November 2026 (the grouper and Addendum B dates are described as tentative). The message also lists hospital re-enrollment due dates running from December 2026 to March 2027, and the source is a recent DSS notice that PolicyChanges found in October 2026.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Preventive Vaccines (Immunizations)
UnitedHealthcare revised the coverage conditions for preventive vaccines (immunizations) on the Exchange plan, effective 2026-12-01. A vaccine is now covered as a preventive benefit only when it has FDA approval, is not excluded in the member's plan document, and either meets the Preventive Care Services vaccine code criteria or has an explicit recommendation (should, shall, is) from the American Academy of Family Physicians, American Academy of Pediatrics, or American College of Obstetricians and Gynecologists; the prior 'not permissive (may)' wording was removed. The policy also adds a reference to the applicable vaccine codes list (CPT 90616, 90657, 90658).
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Preventive Vaccines (Immunizations)
UMR revised its preventive vaccine (immunization) coverage criteria so that a vaccine is covered as a preventive care service when it is subject to explicit recommendations (should, shall, is) from the American Academy of Family Physicians, American Academy of Pediatrics, or American College of Obstetricians and Gynecologists, and the earlier requirement that recommendations not be permissive ('may') was removed. The FDA-approval and plan-exclusion conditions still apply, and the policy adds a reference to the applicable vaccine codes list (CPT 90616, 90657, 90658). Billing staff should review vaccine claims for these plans to confirm the codes and recommendation basis they submit align with the updated criteria.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Preventive Vaccines (Immunizations)
Effective 2026-12-01, the Surest preventive vaccine coverage criteria change so that a vaccine is covered as a preventive care service when it has explicit (should/shall/is) recommendations from AAFP, AAP, or ACOG; the prior requirement that the recommendation not be permissive ('may') has been removed. The policy also adds a reference to the applicable vaccine codes list, covering CPT 90616, 90657, and 90658.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Preventive Vaccines (Immunizations)
UnitedHealthcare revised the coverage conditions for preventive vaccines (immunizations) under its commercial medical policy. A vaccine now qualifies as a covered preventive care service when it carries an explicit recommendation (should, shall, is) from the American Academy of Family Physicians, American Academy of Pediatrics, or American College of Obstetricians and Gynecologists; the prior wording also required that recommendations not be permissive ('may'). The policy also adds a reference to the Professional Medical Society Preventive Vaccine Recommendations vaccine codes list (CPT 90616, 90657, 90658).
MassHealth · Effective Dec 1, 2026Medium impact
HCBS Waiver Provider Bulletin 28: Implementation of National Provider Identifier (NPI) Number
MassHealth requires HCBS waiver providers in the ABI and MFP programs that bill MassHealth directly to obtain and use a National Provider Identifier (NPI). New providers must furnish their NPI with their initial application starting December 1, 2026, and existing providers must furnish it at their regularly scheduled recredentialing, with earlier requests made by the HCBS Provider Network Administration Unit. Beginning May 1, 2028, NPIs must appear on all claims, and claims without the billing provider's NPI will be denied.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Cardiovascular Disease Risk Tests (for Ohio Only)
UnitedHealthcare Community Plan of Ohio has revised its Cardiovascular Disease Risk Tests policy to clarify unproven and not medically necessary indications, specifically adding noninvasive point-of-care cardiac diagnostic platforms (e.g., CorVista® System) to the non-covered list and removing CPT code 83695 from coverage. Effective December 1, 2026, Ohio Medicaid providers must stop billing for these tests and update denial protocols accordingly.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Breast Imaging for Screening and Diagnosing Cancer (for New Mexico Only)
UnitedHealthcare Community Plan of New Mexico (Medicaid) revised its breast imaging policy effective December 1, 2026, narrowing coverage for molecular breast imaging by explicitly excluding routine screening use and clarifying that Positron Emission Mammography is not covered. The policy also refined terminology for MRI elastography and updated clinical evidence. Billing teams must ensure claims for excluded modalities are not submitted for routine screening cases, even in high-risk patients.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Breast Imaging for Screening and Diagnosing Cancer (for Kansas Only)
UnitedHealthcare Community Plan of Kansas (Medicaid) is revising its breast imaging medical policy effective December 1, 2026, to clarify that certain advanced imaging modalities (Magnetic Resonance Elastography of the Breast, Molecular Breast Imaging, Computed Tomography of the breast, and Computer-Aided Tactile Breast Imaging) remain unproven and not medically necessary for routine screening in normal or high-risk individuals. The policy updates terminology and removes outdated definitions but does not change coverage for conventional mammography.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (September 2026 Newsletter)
Carelon Medical Benefits Management has updated prior authorization and precertification requirements for Virginia commercial plans, effective December 1, 2026. Changes span Additional Outpatient and Cardiovascular service categories. The billing team must identify which specific procedures now require prior authorization under these updated guidelines.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Virginia] Precertification/prior authorization list change notification
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in Virginia is adding compression devices for lymphedema (HCPCS code E0659) to its precertification/prior authorization requirements. Providers must obtain prior authorization before rendering this service or claims may be denied as ineligible for payment.
Anthem BCBS · Effective Dec 1, 2026Medium impact
[Georgia] Precertification/prior authorization list change notification
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Georgia is adding compression devices for lymphedema (HCPCS code E0659) to its precertification/prior authorization requirements for commercial plans. All claims for this service will require prior authorization approval before processing to avoid denials.
Independence Blue Cross · Effective Dec 2, 2026Medium impact
12.00.04, Remote Physiologic Monitoring and Remote Therapeutic Monitoring
Effective 12/02/2026, Independence Blue Cross establishes a new medical policy covering remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) for commercial members with specific chronic and acute conditions (CHF, hypertension, diabetes) when medically necessary criteria are met. The policy defines covered CPT and HCPCS codes, requires FDA-approved devices, patient consent documentation, provider supervision, and limits initial coverage to specific monitoring periods with documented clinical justification for extensions beyond 60 days.
Ohio Medicaid · Effective Dec 3, 2026Medium impact
5160-12-08 - Registered nurse assessment and registered nurse consultation services. (New/Original File)
The Ohio Department of Medicaid filed a new rule (5160-12-08) on registered nurse assessment and consultation services, effective December 3, 2026. The source document provided is an index listing of regulatory filings and historical actions but does not contain the actual rule text, specific billing codes, coverage criteria, or billing requirements needed to determine what your practice must do.

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MMP 26-47: Maternal Infant Health Program Rate Increase and Update to Care Coordination Requirements

Updates to the Durable Medical Equipment Services Manual

HealthPro News – October 2026

Cardiovascular Disease Risk Tests (for New Mexico Only)

Breast Imaging for Screening and Diagnosing Cancer (for Kentucky Only)

[Ohio] Avalon Policy Updates

[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

Leveling for Facility Claims

NC Integrated Care for Kids Closeout and Related Billing Code Changes

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

[Ohio] 2027 Medicare formulary changes: Prepare now for

Targeted Case Management Program for Chronic Diseases (TCMP CD) - LB 527

ValueBlue Partial Capitation Reimbursement Begins Jan. 1, 2027

MMP 26-46: Updates to Coverage of Maternity Care Services

BT2026182: COVID-19 vaccine administration to no longer be carved out of managed care

BT2026171: IHCP corrects claim processing for FQHC and RHC encounter billing of codes T1015 and D9999

Ambetter Health Billing Code Update for various HCPC H Codes: Effective 01/01/2027

All Provider Bulletin 421: Enrollment Requirement for All Providers on Claims Submitted to MassHealth - Corrected

Januvia (sitagliptin) (New)

Janumet (sitagliptin and metformin hydrochloride) (New)

Michigan: The MCT2D CGM prior auth bypass will end on Jan. 1

DPP-IV, SGLT2 Combination Products (New)

Evolving Primary Care Reimbursement in 2027: Introducing ValueBlue and ValueBlue Connect

Ambetter of Tennessee Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Absolute Total Care Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter of North Carolina Inc. Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Louisiana Healthcare Connections Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from WellCare of Kentucky Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Peach State Health Plan Billing Code Update for various HCPC H Codes: Effective 01/01/2027

Ambetter from Sunflower Health Plan Billing Code Update for various HCPC H Codes Effective 01/01/2027

Maternity Care Services Global CPT Code Changes

Transition to American Medical Association Maternity Current Procedural Terminology 2027 Code Changes Effective Jan. 1, 2027

DSS Important Message - Hospital Monthly Important Message - 10.19.2026

Preventive Vaccines (Immunizations)

Preventive Vaccines (Immunizations)

Preventive Vaccines (Immunizations)

Preventive Vaccines (Immunizations)

HCBS Waiver Provider Bulletin 28: Implementation of National Provider Identifier (NPI) Number

Cardiovascular Disease Risk Tests (for Ohio Only)

Breast Imaging for Screening and Diagnosing Cancer (for New Mexico Only)

Breast Imaging for Screening and Diagnosing Cancer (for Kansas Only)

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (September 2026 Newsletter)

[Virginia] Precertification/prior authorization list change notification

[Georgia] Precertification/prior authorization list change notification

12.00.04, Remote Physiologic Monitoring and Remote Therapeutic Monitoring

5160-12-08 - Registered nurse assessment and registered nurse consultation services. (New/Original File)