What insurance policy changes affect Iowa providers?

This page tracks changes from major payers (including Medicaid managed care, commercial insurers, and Medicare Advantage plans) that explicitly apply to Iowa. Changes include prior authorization updates, billing code additions or deletions, and reimbursement rate revisions.

How often are Iowa policy changes updated?

Our scrapers run daily and publish new findings within 24 hours of detection. Each change includes an effective date where stated so you can prioritize what requires immediate action.

How do I get alerted to new Iowa insurance policy changes?

Create a free alert on PolicyChanges.app and filter by state to Iowa. You will get an email when new matching changes are detected: daily or weekly, your choice, on every plan.

PAYER POLICY CHANGES

Iowa Insurance & Medicaid Policy Updates

Iowa providers face a continuous stream of payer policy changes: coverage edits, prior authorization expansions, billing code revisions, and Medicaid reimbursement updates that affect day-to-day practice operations. This page surfaces every tracked policy change that explicitly names Iowa, so your billing and compliance teams can act before the effective date, not after a claim denial.

Iowa Medicaid · Effective Dec 1, 2026High impact
IL 2742-MC-FFS: Pharmacy Benefit Carve-Out
Effective December 1, 2026, Iowa Medicaid is transitioning outpatient pharmacy benefits for managed care members from MCO administration to fee-for-service administration through Optum Rx. All outpatient pharmacy claims with dates of service on or after December 1, 2026, must be submitted using new point-of-sale information (BIN: 011933, PCN: IAPOP) and will be processed by Optum Rx instead of MCOs. Prior authorizations will also be administered by Optum Rx beginning December 1, 2026.
Ambetter · Effective Dec 2, 2026High impact
Revision to Payment Platform Transition from Payspan to Zelis
Centene is transitioning claims payment processing from Payspan to the Zelis platform, with phased conversions beginning December 2, 2026 (WellCare Medicare) and extending through February 5, 2027 (Iowa Total Care Medicaid and WellCare Dual Eligible). Practices must enroll in a Zelis payment method (ZAPP Edge, Virtual Card, ePayment Center, or Paper Check) before their line of business converts to avoid payment disruption or default to paper checks.
UnitedHealthcare · Effective Jan 1, 2027High impact
New oncology prior authorization code updates
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
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 is discontinuing coverage for 52 HCPCS H codes related to alcohol/drug treatment, behavioral health services, and mental health support. Simultaneously, H0006 (Alcohol/drug service, case management) will become newly covered. The billing team must immediately identify affected claims in the system and implement denial protocols for non-covered codes starting January 1, 2027.
Ambetter · Effective Nov 6, 2026High impact
Provider Alert: Payment Platform Transition from Payspan to Zelis
Effective November 2026, provider claim payments and remittance information will transition from Payspan to the Zelis payment platform. This is a payment delivery and access change only—reimbursement rates, claims adjudication, and payment methodology remain unchanged. The billing team must verify current payment setup, confirm electronic payment methods, and coordinate enrollment before staggered conversion dates by line of business.
Humana · Effective Oct 1, 2026High impact
Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
Humana · Effective Oct 1, 2026High impact
Bariatric Surgery - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage bariatric surgery coverage policy (HUM-1020-005) effective October 1, 2026, that outlines coverage determinations, limitations, and coding requirements for various bariatric procedures. The policy applies Humana's Medicare Advantage coverage standards and references applicable MAC Local Coverage Determinations by geographic jurisdiction, with specific rules varying by state and MAC region.
Ambetter · Effective Oct 1, 2026High impact
Evolent Prior Authorization Updates: Effective October 1, 2026
Evolent Specialty Services requires prior authorization for 23 cardiology codes covering angioplasty, stent placement and atherectomy in the iliac, femoral and popliteal, tibial and peroneal, and inframalleolar arteries, plus code 92930 for placement of intracoronary stents. The requirement takes effect October 1, 2026 for members of the Iowa Total Care Medicaid and Ambetter Health Marketplace health plans.
Humana · Effective Sep 1, 2026High impact
Spinal Fusion Surgery - Medicare Advantage (Revised)
This is a revised Medicare Advantage medical coverage policy for spinal fusion surgery (effective 09/01/2026) that consolidates coverage determination, limitations, coding information, and evidence summaries for cervical, lumbar, and thoracic spinal fusion procedures. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) across geographic jurisdictions and outlines covered procedures including traditional fusion, minimally invasive approaches (DLIF, XLIF, MITLIF), sacroiliac joint fusion, and interlaminar fusion techniques. Billing teams must align claims submission with the applicable MAC LCD based on patient location and ensure procedures meet specific medical necessity criteria outlined in the referenced determinations.
Humana · Effective Sep 1, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for Benign Prostatic Hyperplasia treatments effective September 1, 2026. The policy outlines coverage determinations for multiple BPH treatment modalities including surgical procedures (TURP, prostatectomy, laser therapies), temporary implanted devices, stents, and diagnostic testing. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) that vary by geographic jurisdiction, requiring billing teams to verify applicable coverage rules based on patient location.
Humana · Effective Sep 1, 2026High impact
Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)
Humana Medicare Advantage has revised its Ambulatory Cardiac Monitoring Devices policy effective September 1, 2026. The policy provides updated coverage guidance for various cardiac monitoring technologies (Holter monitors, patch recorders, external loop monitors, implantable loop recorders, and mobile cardiac outpatient telemetry) with MAC-specific coverage determinations by geographic jurisdiction. The policy document appears incomplete but establishes that medical necessity determinations will follow applicable NCDs and LCDs based on the member's jurisdiction.
Ambetter · Effective Aug 7, 2026High impact
Provider Manual Update
Ambe Better Health has updated its Provider Manual to clarify inpatient billing requirements for Type of Bill (TOB) 86x and address variability in provider billing across inpatient (11x), residential treatment center (86x), and outpatient (13x, 76x) settings. A new BH TOB scenario document has been created to provide specific guidance on revenue and procedure code usage for each billing type.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for neuroablative techniques used to treat chronic pain, effective 08/06/2026. The policy defines coverage criteria, eligible procedures (including radiofrequency ablation, cryoablation, chemical neurolysis, and specialized devices like Intracept), and references MAC-specific LCDs and billing codes by geographic jurisdiction. Billing teams must verify applicable MAC guidelines for their state and ensure claims comply with local coverage determinations.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy on neuroablative techniques for chronic pain management, effective 08/06/2026. The policy defines covered denervation procedures (radiofrequency ablation, cryoablation, facet denervation, basivertebral nerve ablation, and others) and references MAC-specific LCDs and NCDs that vary by geographic jurisdiction. Billing teams must verify applicable MAC requirements for their region before processing claims for these procedures.
Humana · Effective Aug 3, 2026High impact
Percutaneous Coronary Intervention - Medicare Advantage (Revised)
Humana Medicare Advantage updated its Percutaneous Coronary Intervention (PCI) coverage policy effective August 3, 2026, clarifying medical necessity criteria for PCI procedures and adding specific coverage requirements for Coronary Intravascular Lithotripsy (IVL) when treating severely calcified coronary stenosis. The policy applies MAC-specific LCDs across multiple jurisdictions and establishes that PCI is covered for acute coronary syndrome, chest pain despite optimal medical therapy, in-stent restenosis, recent STEMI, and silent ischemia.
Humana · Effective Aug 3, 2026High impact
Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy on genetic testing for hereditary cancer syndromes, effective August 3, 2026. The policy establishes coverage guidelines for germline genetic testing across multiple cancer types (melanoma, gastric cancer, neuroendocrine tumors, renal cell carcinoma, and others) and references specific MAC-based Local Coverage Determinations (LCDs) that vary by geographic jurisdiction. Billing teams must verify applicable MAC jurisdiction and LCD requirements before processing claims.
Humana · Effective Aug 3, 2026High impact
Cardiac Catheterization and Coronary Angiography - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its cardiac catheterization and coronary angiography coverage policy (Policy HUM-1034-008), effective 08/03/2026. The policy establishes specific medical necessity criteria for coronary/bypass angiography procedures, requiring documented moderate to severe ischemia confirmed by nuclear imaging, echocardiography, cardiac MRI, or exercise testing. Billing teams must verify these criteria are met and documented before submitting claims to avoid denials.
Humana · Effective Aug 3, 2026High impact
Breast Reconstruction - Medicare Advantage (Revised)
Humana Medicare Advantage has revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
Humana · Effective Aug 3, 2026High impact
Breast Excision and Mastectomy - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its Breast Excision and Mastectomy policy (HUM-1254-009) effective 08/03/2026. This revised policy clarifies coverage criteria for breast lesion excisions (CPT 19120, 19125), partial mastectomies (CPT 19301, 19302), and gynecomastia mastectomy (CPT 19300) across multiple MAC jurisdictions. The policy establishes specific medical necessity criteria based on biopsy results, lesion characteristics, and anatomical considerations, and applies jurisdiction-specific Local Coverage Determinations (LCDs) for Medicare Administrative Contractors.
Humana · Effective Aug 3, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy for Benign Prostatic Hyperplasia (BPH) treatments that became effective on August 3, 2026. The policy outlines coverage for multiple surgical and minimally invasive treatment modalities including TURP, laser therapies, temporary implanted devices, and stents, with specific coverage determinations varying by MAC jurisdiction. Billing teams must verify applicable MAC-specific LCDs and NCDs by geographic location before processing BPH treatment claims.
Iowa Medicaid · Effective Jul 27, 2026High impact
IL 2739-FFS: Iowa Medicaid Pharmacy Program Changes: PBA Transition to Optum Rx
Iowa Medicaid FFS pharmacy benefit administrator is transitioning from Change Healthcare to Optum Rx effective July 27, 2026. There will be a 3-hour blackout period (8:00 PM – 11:00 PM CST) during which pharmacy claims will be rejected and must be resubmitted after 11:00 PM CST. Prior authorizations submitted after 2:00 PM CST on 7/27/26 must be resubmitted after 8:00 AM CST on 7/28/26. BIN, PCN, and contact information remain unchanged, but coordination of benefits policies and third-party liability requirements for members under 21 are being updated.
Iowa Medicaid · Effective Jul 1, 2026High impact
IL 2735-FFS-D: MCNA Dental Exit and Transition
MCNA Dental is exiting Iowa's Dental Wellness Plan effective July 1, 2026, with DentaQuest replacing it as a new dental plan option. Providers must submit claims to the correct dental plan based on service dates and verify member eligibility through ELVS.
Iowa Medicaid · Effective Jun 17, 2026High impact
IL 2738-FFS: Statewide Provider Revalidation Initiative
Iowa Medicaid is launching a mandatory statewide provider revalidation initiative from July 1, 2026 through June 30, 2028. All Iowa Medicaid FFS providers will receive phased revalidation notices and have 30 days to complete the revalidation process once notified.
Ambetter · Effective Jun 15, 2026High impact
Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 6/15/26
Effective June 15, 2026, Ambetter Health is implementing new billing and payment requirements for Intraoperative Neurophysiologic Monitoring (IONM) services on Marketplace plans. Only CMS-recognized payable code 95940 with modifier G0453 is covered; code 95941 is non-covered. All claims must meet strict criteria including exclusive patient attention, maximum 4 units per 60 minutes, appropriate place of service codes, and cannot be billed by surgeon or anesthesia provider.
UnitedHealthcare · Effective Apr 1, 2026High impact
New DME process for select members in multiple states
Beginning April 1, 2026, Synapse Health will manage durable medical equipment (DME) ordering and fulfillment for UnitedHealthcare Medicare Advantage plans in multiple states. DME prescribers must use Synapse Health's e-prescribing portal, and DME providers must join the Synapse Health network to continue serving these members.
UnitedHealthcare · Identified Sep 2, 2026High impact
Hereditary cancer testing policy reminder
UnitedHealthcare is reminding providers that multigene RNA panel testing for hereditary cancer is considered unproven and will be denied. Only DNA-only hereditary cancer panels and single-gene RNA testing remain covered under applicable medical policy and prior authorization requirements.
Humana · Effective Nov 1, 2026Medium impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
Humana Medicare Advantage revised its neuroablative techniques for chronic pain policy effective 11/01/2026. The policy update describes coverage criteria, limitations, and coding guidance for multiple denervation procedures (radiofrequency ablation, cryotherapy, facet denervation, basivertebral nerve ablation, and other neuroablative techniques). The practice must verify applicable MAC LCDs by geographic jurisdiction, obtain prior authorization as required, and ensure claims are submitted with correct coding and documentation.
Molina Healthcare · Effective Oct 26, 2026Medium impact
08-28-2026 Coming soon: New provider enrollment and credentialing portal IM IE LA OC SAC SD
Molina Healthcare is launching a new Provider Network Management Portal on October 26, 2026, that will replace email and paper-based provider enrollment and credentialing submissions for directly contracted providers. All direct provider enrollment and credentialing requests must be submitted through this new portal starting that date. This change does not affect delegated IPAs (which use D360) or Availity functionality (claims, prior auth, member panels).
Iowa Medicaid · Effective Oct 1, 2026Medium impact
IL 2741-MC-FFS-D: IA Health Link – Managed Care Wraparounds Payments
Iowa Medicaid has updated IA Health Link Managed Care Wraparound Payments effective October 1, 2026. This informational letter directs FQHCs and RHCs to visit the Iowa Medicaid provider services page for details on the specific payment changes; however, the letter itself does not specify what those changes entail.
Humana · Effective Oct 1, 2026Medium impact
Noninvasive Tests for Hepatic Fibrosis - Medicare Advantage (Revised)
This is a Medicare Advantage policy update (effective 10/01/2026) covering noninvasive tests for hepatic fibrosis, including imaging-based tests (MRE, qMRA) and blood-based biomarker panels (ELF, FIB-4, FibroSure, LiverFASt, NIS4, OWLiver, TruD, HepQuantDuO). The policy establishes coverage determination criteria for these tests across multiple MAC jurisdictions. The document provided is incomplete and does not contain the full coverage determination criteria, medical necessity requirements, or specific billing code guidance needed for implementation.
Humana · Effective Oct 1, 2026Medium impact
Low Frequency, Noncontact, Nonthermal Ultrasound for Wound Care - Medicare Advantage (Revised)
This is a revised Medicare Advantage policy for low frequency, noncontact, nonthermal ultrasound (MIST Therapy) for wound care, effective October 1, 2026. The policy clarifies medical necessity criteria across multiple MAC jurisdictions, requiring that standard wound care demonstrate no improvement or be contraindicated before this therapy is covered. Billing teams must ensure claims include proper documentation of failed standard care and route requests through applicable regional MACs.
Iowa Medicaid · Effective Oct 1, 2026Medium impact
IL 2740-MC-FFS: 2740 SFY27 Home and Community-Based Services (HCBS) Waiver Rate Changes
Iowa Medicaid is increasing reimbursement rates for four specific HCBS Waiver services (Assisted Living, Attendant Care–Unskilled, Attendant Care–Skilled, and Home Maintenance Support) effective October 1, 2026. Billing teams must verify updated fee schedules and ensure claims are submitted using the correct billing codes (T2031, S5125, S5125 U3, S5130) to capture the new higher rates.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter Health is updating prior authorization requirements effective October 1, 2026. The changes remove PA requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208), while adding PA requirements for sinus surgery procedures (31276, 31296, 31297, 31298). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
UnitedHealthcare · Effective Oct 1, 2026Medium impact
New oncology prior authorization code update
Effective October 1, 2026, UnitedHealthcare will require prior authorization for HCPCS code J2860 (siltuximab injection) when administered in outpatient settings for cancer treatment. This applies to all UnitedHealthcare plan types including commercial, Medicare Advantage, Medicaid, and Exchange plans.
Humana · Effective Aug 30, 2026Medium impact
Molecular Diagnostic Assays and Breath Testing for Transplant Rejection - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its policy on molecular diagnostic assays and breath testing for transplant rejection, effective 08/30/2026. This policy establishes coverage criteria and references for gene expression profiling tests, antigen-specific T-cell function assays, breath testing (BMAC/Heartsbreath), and donor-derived cell-free DNA tests used to monitor organ transplant recipients. Billing teams must verify MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction, as coverage and coding requirements vary significantly by region.
Humana · Effective Aug 3, 2026Medium impact
Liquid Biopsy - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its Liquid Biopsy coverage policy (Policy HUM-1151-014), effective 08/03/2026. This policy establishes coverage criteria for liquid biopsy tests (blood-based biomarker analysis for cancer detection and treatment monitoring) across multiple jurisdictions under Medicare Administrative Contractors. The policy requires medical necessity documentation and adherence to MAC-specific Local Coverage Determinations, with coverage determined through analytical/clinical validity standards and DEX Registry evaluation where CMS guidance is absent.
HealthPartners · Effective Aug 1, 2026Medium impact
Fast Facts Newsletter - June (Special Edition) 2026
HealthPartners has updated multiple medical policies effective immediately and August 1, 2026, including expanded cardiac monitoring coverage, new prior authorization requirements for prosthetic devices, consolidated nutritional support policies, and new reimbursement policies for single-dose vial billing and 3D imaging services.
Humana · Effective Jul 1, 2026Medium impact
Coronary CT Angiography, Fractional Flow Reserve with CT and Adjunctive Testing - Medicare Advantage (Revised)
This is a Medicare Advantage policy revision (effective 07/01/2026) for Coronary CT Angiography, Fractional Flow Reserve with CT, and adjunctive cardiac testing. The policy establishes that Humana follows applicable Local Coverage Determinations (LCDs) by MAC jurisdiction for CCTA (CPT 75574) and FFRCT (CPT 75580), with specific LCD guidance for each geographic region. Billing teams must ensure prior authorization and medical necessity documentation align with the applicable LCD in the patient's service area.
Iowa Medicaid · Effective Jul 1, 2026Medium impact
IL 2734-FFS-D: Dental Wellness Plan (DWP) and Hawki Provider Information
Iowa Medicaid is adding DentaQuest as a second dental plan alongside Delta Dental of Iowa for Dental Wellness Plan and Hawki members effective July 1, 2026. Dental providers must be enrolled with Iowa Medicaid first, then contract directly with either or both dental plans to continue serving these patients.
Humana · Effective Jun 1, 2026Medium impact
Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments - Medicare Advantage (Revised)
Humana Medicare Advantage updated coverage criteria for obstructive sleep apnea surgical treatments, establishing specific medical necessity requirements for procedures like uvulopalatopharyngoplasty and genioglossal advancement, while excluding coverage for certain procedures like tongue-based suspension surgery and uvulectomy as standalone OSA treatment.
UnitedHealthcare · Effective Jun 1, 2026Medium impact
New DME process for select members in multiple states
Starting June 1, 2026, Synapse Health will manage DME ordering and fulfillment for UnitedHealthcare Medicare Advantage plans in multiple states. DME prescribers must use the Synapse Health e-prescribing portal, and DME providers must join the Synapse Health network to continue providing services.
Aetna · Effective Jun 1, 2026Medium impact
OfficeLink Updates - March 2026 newsletter
This is an informational newsletter (OfficeLink Updates - March 2026) containing multiple policy updates and operational guidance for Aetna providers. Key items include: (1) new claim edits effective June 1, 2026 as part of the Claim and Code Review Program (CCRP); (2) an update to the treatment room services policy (originally effective April 1, 2021); and (3) reminders about prior authorization submission procedures, provider profile maintenance, and behavioral health resources. The newsletter applies to Commercial and Medicare lines of business unless otherwise specified.
Humana · Effective Apr 1, 2026Medium impact
Cardiac Catheterization and Coronary Angiography - Medicare Advantage (Revised)
Humana Medicare Advantage has updated coverage criteria for cardiac catheterization and coronary angiography procedures (CPT 93454-93461), specifying detailed requirements for moderate to severe ischemia documentation and stress test results. The policy establishes specific thresholds for nuclear perfusion, echocardiogram, and other diagnostic tests that must be met for coverage approval.
Humana · Effective Feb 2, 2026Medium impact
Psychological and Neuropsychological Testing - Medicare Advantage (New)
Humana has released a new Medicare Advantage medical coverage policy for psychological and neuropsychological testing, establishing coverage criteria and billing guidelines for related CPT codes. This policy references multiple Medicare Administrative Contractor (MAC) Local Coverage Determinations across different states to determine medical necessity requirements.
UnitedHealthcare · Effective Feb 1, 2026Medium impact
AARP Medicare Supplement: Change to overpayment reimbursement process
AARP Medicare Supplement plans from UnitedHealthcare will automatically offset overpayments from future ACH electronic payments instead of sending letters requesting refunds. This streamlined process applies to providers receiving electronic payments through Optum Pay in 33 specified states.
Iowa Medicaid · Effective Dec 1, 2025Medium impact
IL 2713-MC-D: Commercial Lesser of Logic - AMENDED
Iowa Medicaid has amended its Commercial Lesser of Logic policy to exclude Certified Community Behavioral Health Clinics (CCBHCs) from the requirement that limits Medicaid payments to the lesser of cost-sharing or the difference between primary insurance payments and Medicaid fees. CCBHCs will now receive full enhanced rate reimbursement regardless of commercial insurance payments.
Wisconsin Medicaid (ForwardHealth) · Effective Oct 1, 2025Medium impact
2025 Hospice Reimbursement Rate Changes
Effective for dates of service on and after October 1, 2025, Wisconsin Medicaid and BadgerCare Plus updated hospice reimbursement rates, which are based on the hourly and per diem rates CMS sets for covered hospice services. Routine home care pays a higher rate for a member's first 60 days of hospice care and a lower rate for day 61 and after, and a service intensity add-on is paid for routine care by a social worker or registered nurse during the last seven days of a member's life. The attachment lists new county rates, with separate rates for rural Wisconsin, Iowa, Illinois, Michigan and Minnesota, and ForwardHealth will automatically adjust previously paid claims for services on and after the effective date.
Iowa Medicaid · Effective Aug 1, 2025Medium impact
IL 2732-MC-FFS: Personal Needs Allowance and Supplemental Personal Needs Payments
Iowa Medicaid increased the Personal Needs Allowance from $50 to $55 monthly for facility residents, effective retroactively to August 1, 2025. System updates are complete and providers should resubmit previously denied claims that were affected by the client participation calculation errors.
HealthPartners · Identified Nov 6, 2026Medium impact
Fast Facts Newsletter - June (Special Edition) 2026
This June 2026 HealthPartners newsletter (issued 2026-06-01, first detected 2026-11-06, so historical material) lists coverage policy revisions, retirements and renames, plus reimbursement policy updates. Several changes are effective 08/01/2026 or 7/1/2026 (future relative to the source date but elapsed relative to the 2026-11-06 analysis date, so verify current applicability), while others were Reported as already effective in the historical source on 06/01/2026. Key items include a prosthesis policy adding prior authorization for protective outer surface covering systems (L5962, L5964), revised cardiac monitoring and cardiovascular risk screening criteria, endocrinology HbA1c criteria, a Minnesota wheelchair/robotic arm documentation update, a lumbar spinal fusion psychiatric evaluation timing change, and Cohere Health revisions for hip/knee arthroscopy, kyphoplasty/vertebroplasty and spinal cord stimulators.
Ambetter · Identified Sep 25, 2026Medium impact
Provider Alert Payspan Migration to Zelis Update (PDF)
Iowa Total Care is migrating from Payspan to Zelis for provider payment processing. Providers now have four payment options: EFT/ERA (free), paper check (free), ZAPP Edge (fee-based), and Virtual Credit Card (fee-based). Billing teams must ensure providers understand enrollment requirements and fees for each option to avoid payment delays or unexpected charges.

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IL 2742-MC-FFS: Pharmacy Benefit Carve-Out

Revision to Payment Platform Transition from Payspan to Zelis

New oncology prior authorization code updates

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

Provider Alert: Payment Platform Transition from Payspan to Zelis

Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)

Bariatric Surgery - Medicare Advantage (Revised)

Evolent Prior Authorization Updates: Effective October 1, 2026

Spinal Fusion Surgery - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)

Provider Manual Update

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Percutaneous Coronary Intervention - Medicare Advantage (Revised)

Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)

Cardiac Catheterization and Coronary Angiography - Medicare Advantage (Revised)

Breast Reconstruction - Medicare Advantage (Revised)

Breast Excision and Mastectomy - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

IL 2739-FFS: Iowa Medicaid Pharmacy Program Changes: PBA Transition to Optum Rx

IL 2735-FFS-D: MCNA Dental Exit and Transition

IL 2738-FFS: Statewide Provider Revalidation Initiative

Intraoperative Neurophysiologic Monitoring (IONM) Update: Effective 6/15/26

New DME process for select members in multiple states

Hereditary cancer testing policy reminder

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

08-28-2026 Coming soon: New provider enrollment and credentialing portal IM IE LA OC SAC SD

IL 2741-MC-FFS-D: IA Health Link – Managed Care Wraparounds Payments

Noninvasive Tests for Hepatic Fibrosis - Medicare Advantage (Revised)

Low Frequency, Noncontact, Nonthermal Ultrasound for Wound Care - Medicare Advantage (Revised)

IL 2740-MC-FFS: 2740 SFY27 Home and Community-Based Services (HCBS) Waiver Rate Changes

Important Prior Authorization Updates: Effective October 1, 2026

New oncology prior authorization code update

Molecular Diagnostic Assays and Breath Testing for Transplant Rejection - Medicare Advantage (Revised)

Liquid Biopsy - Medicare Advantage (Revised)

Fast Facts Newsletter - June (Special Edition) 2026

Coronary CT Angiography, Fractional Flow Reserve with CT and Adjunctive Testing - Medicare Advantage (Revised)

IL 2734-FFS-D: Dental Wellness Plan (DWP) and Hawki Provider Information

Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments - Medicare Advantage (Revised)

New DME process for select members in multiple states

OfficeLink Updates - March 2026 newsletter

Cardiac Catheterization and Coronary Angiography - Medicare Advantage (Revised)

Psychological and Neuropsychological Testing - Medicare Advantage (New)

AARP Medicare Supplement: Change to overpayment reimbursement process

IL 2713-MC-D: Commercial Lesser of Logic - AMENDED

2025 Hospice Reimbursement Rate Changes

IL 2732-MC-FFS: Personal Needs Allowance and Supplemental Personal Needs Payments

Fast Facts Newsletter - June (Special Edition) 2026

Provider Alert Payspan Migration to Zelis Update (PDF)