What insurance policy changes affect Idaho providers?

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

How often are Idaho 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 Idaho insurance policy changes?

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

PAYER POLICY CHANGES

Idaho Insurance & Medicaid Policy Updates

Idaho 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 Idaho, so your billing and compliance teams can act before the effective date, not after a claim denial.

UnitedHealthcare · Effective Dec 1, 2026High impact
Treatment of Temporomandibular Joint Disorders (for Idaho Only)
UnitedHealthcare Community Plan of Idaho revised its Medicaid medical policy on treatment of temporomandibular joint (TMJ) disorders, effective 2026-12-01. TMJ arthroplasty is now the only TMJ surgical service described as proven and medically necessary in certain circumstances, with medical necessity criteria pointing to InterQual CP: Procedures, Arthroplasty, Temporomandibular Joint (TMJ) (Custom) - UHG; arthroscopy and discectomy criteria were removed. CPT codes 21060, 21247, 29800, and 29804 were removed from the applicable codes list.
UnitedHealthcare · Effective Dec 1, 2026High impact
Surgery of the Shoulder (for Idaho Only)
Effective 2026-12-01, UnitedHealthcare Community Plan of Idaho revised its Surgery of the Shoulder medical policy for Idaho Medicaid members: medical necessity criteria now point to InterQual CP procedure criteria for shoulder arthroscopy, arthrotomy and joint replacement, and CPT 29805 was removed from the applicable codes. The policy also states that subacromial balloon spacers for rotator cuff tears are unproven and not medically necessary.
PacificSource Health Plans · Effective Dec 22, 2026High impact
December 2026 Drug List Change Notification (Commercial)
PacificSource is implementing comprehensive drug list changes effective December 22, 2026, including 24 new formulary additions across commercial and state-based plans (OR, ID, MT, WA), updates to prior authorization criteria for 11 drug classes, and removal of prior authorization requirements for Breztri aerosol. The billing team must update prior authorization workflows, tier assignments, quantity limits, and step therapy requirements in billing systems to reflect these changes.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for Idaho Only)
UnitedHealthcare Community Plan of Idaho revised its Medicaid medical policy for transarterial radioembolization (TARE)/selective internal radiation therapy (SIRT) using yttrium-90 microspheres for liver malignancies, effective 2026-12-01. The proven-and-medically-necessary indications were updated, changing the uveal melanoma indication to read "metastasis from uveal melanoma when confined to the liver," and the TARE definition was updated; HCPCS S2095 was flagged as not on the Idaho Medicaid fee schedule and may not be covered by the Idaho Medicaid program.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Surgery of the Hip (for Idaho Only)
UnitedHealthcare Community Plan of Idaho revised its Medicaid medical policy for hip surgery, effective 2026-12-01. Medical necessity criteria now point to InterQual® procedure criteria instead of the prior CP reference, CPT 29860 was removed from the applicable codes, and the HOOS definition was updated. Surgical treatment for Femoroacetabular Impingement Syndrome is stated as unproven and not medically necessary when advanced osteoarthritis (Tönnis grade 2 or 3) or severe cartilage damage (Outerbridge grade III or IV) is present.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Obstructive and Central Sleep Apnea Treatment (for Idaho Only)
Effective 2026-12-01, the Idaho Medicaid (UnitedHealthcare Community Plan of Idaho) medical policy for obstructive and central sleep apnea treatment was revised. Radiofrequency ablation of the soft palate and/or tongue base was added to the list of procedures treated as unproven and not medically necessary for OSA, and implantable phrenic nerve stimulation devices (e.g., remedē) for central sleep apnea are listed as unproven and not medically necessary. Hypoglossal nerve stimulation and surgical criteria (AHI thresholds, PAP failure, Epworth score, and drug-induced sleep endoscopy requirements) are restated in the policy.
Blue Cross of Idaho · Effective Dec 1, 2026Medium impact
MP 5.01.28 Treatment for Spinal Muscular Atrophy - Concurrent use of risdiplam with onasemnogene abeparvovec-xioi and/or nusinersen is considered investigational.
Concurrent use of risdiplam with onasemnogene abeparvovec-xioi and/or nusinersen is considered investigational, as is concurrent use of nusinersen or onasemnogene abeparvovec-xioi with the other therapies, and use of nusinersen or risdiplam after onasemnogene abeparvovec-xioi. Nusinersen, onasemnogene abeparvovec-xioi and risdiplam may be considered medically necessary when all of their listed conditions are met, and the current version ends 11/30/2026 while a pending version takes effect 12/01/2026.
Regence BlueShield · Effective Nov 1, 2026High impact
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder
This is a medical policy for Applied Behavior Analysis (ABA) treatment of Autism Spectrum Disorder, effective November 1, 2026. The policy establishes coverage criteria requiring prior authorization for certain member contracts, documented diagnosis by qualified providers, individualized treatment plans with specific clinical documentation, and ongoing progress monitoring. Billing teams must verify which member contracts require prior auth, obtain authorization before services begin, and ensure claims include required clinical documentation to support medical necessity.
UnitedHealthcare · Effective Nov 1, 2026High impact
Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for Idaho Only)
UnitedHealthcare Community Plan of Idaho (Medicaid) added six molecular oncology testing CPT codes (0631U, 0641U, 0642U, 0643U, 0646U, 0647U) to policy effective November 1, 2026, but flagged them as NOT on the Idaho Medicaid Fee Schedule and therefore NOT covered. Billing teams must treat these codes as non-covered services and verify coverage before billing.
UnitedHealthcare · Effective Nov 1, 2026High impact
Genetic Testing for Neurological Disorders (for Idaho Only)
UnitedHealthcare Community Plan of Idaho revised genetic testing coverage criteria for neurological disorders, effective November 1, 2026. Key changes: (1) Broadened provider consultation requirements from 'ordered by' to 'ordered by or in consultation with' specialists, allowing more flexibility; (2) CPT codes 0216U and 0217U are now flagged as NOT covered by Idaho Medicaid and may not be billed; (3) Removed definitions for WES/WGS and updated supporting clinical evidence. Targeted Panel testing (5+ genes) for specific neurological conditions remains covered if criteria are met.
UnitedHealthcare · Effective Nov 1, 2026High impact
Spinal Fusion and Decompression (for Idaho Only)
UnitedHealthcare Community Plan of Idaho revised its spinal fusion and decompression medical policy effective November 1, 2026. Key changes include: (1) updated reference criteria to use InterQual® Client Defined Custom criteria for lumbar procedures instead of standard InterQual® criteria; (2) added new clinical definitions for instability classifications; and (3) clarified that staged/serial treatment of multisite spinal pathology and certain procedures (dynamic stabilization, facet joint replacement, vertebral joint implants) are not medically necessary. Billing teams must align prior authorization requirements and claim submissions to these new clinical criteria.
Regence BlueShield · Effective Nov 1, 2026High impact
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder
This is a new medical policy effective November 1, 2026, establishing coverage criteria for Applied Behavior Analysis (ABA) therapy in the treatment of Autism Spectrum Disorder. The policy requires prior authorization, detailed individualized treatment plans, certified provider supervision, and documented functional progress for initial assessment, initiation, and continuation of ABA services. Billing teams must prepare systems now to implement preauthorization workflows and documentation requirements before the November 2026 effective date.
PacificSource Health Plans · Effective Oct 22, 2026High impact
October 2026 Drug List Change Notification (Commercial)
Effective October 22, 2026, PacificSource is implementing major formulary changes affecting 40+ medications across commercial and state-based plans (OR, ID, MT, WA). Changes include new drug additions at various tiers with prior authorization and quantity limits, removal of brand-name drugs with generic alternatives, and updates to prior authorization criteria for multiple drug classes. Billing teams must update systems to reflect new tier placements, prior authorization requirements, and quantity limit enforcement.
Blue Cross of Idaho · Effective Oct 15, 2026High impact
MAPAP310 - Medicare Advantage Referral Requirements - Removed referral requirement and details per October 15, 2026, changes to only require referrals for out-of-network specialties services.
Effective October 15, 2026, Blue Cross of Idaho Medicare Advantage plans removed the referral requirement for in-network specialty care. Referrals are now required only for out-of-network specialty services. PCPs must continue submitting referrals electronically for out-of-network referrals, but in-network specialty visits no longer require prior referral authorization.
Blue Cross of Idaho · Effective Oct 1, 2026High impact
PAP313 - DRG Validation Review - New
Blue Cross of Idaho has issued a new provider administrative policy (PAP313) establishing formal procedures for DRG validation reviews on inpatient hospital claims. The policy authorizes pre-payment and post-payment review of diagnosis coding, procedure coding, and DRG assignment; unsupported diagnoses may be removed, resulting in DRG reassignment and claim reprocessing with potential reimbursement adjustments or recovery of overpayments.
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.
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.
UnitedHealthcare · Effective Oct 1, 2026High impact
Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Idaho Only)
UnitedHealthcare Community Plan of Idaho (Medicaid) updated its policy on Continuous Glucose Monitoring and Insulin Delivery effective October 1, 2026. Eight specific HCPCS and CPT codes (0446T, 0448T, S1030, S1031, S1034, S1035, S1036, S1037) are now flagged as NOT on the Idaho Medicaid Fee Schedule and may not be covered; billing teams must verify coverage through the Idaho Medicaid Provider Handbook before submitting claims for these codes.
UnitedHealthcare · Effective Oct 1, 2026High impact
Brow Ptosis and Eyelid Repair (for Idaho Only)
UnitedHealthcare Community Plan of Idaho (Medicaid) revised coverage criteria for eyelid and brow ptosis repair procedures effective October 1, 2026. Key changes include: (1) lower eyelid blepharoplasty is now explicitly considered reconstructive under certain circumstances, (2) lid retraction surgery (CPT 67911) for thyroid eye disease now has separate, expanded medical necessity criteria, and (3) new specific documentation requirements for floppy eyelid syndrome repair including photographic evidence and detailed clinical findings. Billing teams must update prior authorization processes and documentation checklists to reflect these narrower, condition-specific criteria.
Blue Cross of Idaho · Effective Sep 1, 2026High impact
PAP281 - Provider External Auditors - Added appeals must be handled through the vendor.
Blue Cross of Idaho has updated PAP281 to clarify that all appeals and inquiries related to vendor-conducted medical record reviews and audits must be handled directly through the vendor, not through standard Blue Cross provider appeal processes (PAP 236 and MAPAP 229). This supersedes previous guidance and establishes the vendor's process as the primary appeal mechanism for claims subject to external audits.
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.
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
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
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.
Blue Cross of Idaho · Effective Aug 1, 2026High impact
MAPAP230 - Use of Modifiers - Updated modifier references for coding changes.
Blue Cross of Idaho updated modifier coding requirements effective August 2026, including mandatory use of XE/XS/XP/XU subset modifiers instead of modifier 59, revised ambulance origin/destination modifier rules, new requirements for film-based X-rays (FX modifier with 20% payment reduction), therapy modifiers (GN/GO/GP), and sex-specific procedure modifiers (KX for professional claims). Billing teams must audit current practices and update systems to enforce these modifiers on applicable claims to avoid denials.
Blue Cross of Idaho · Effective Jul 1, 2026High impact
PAP206 - Submitting Corrected Claims - Updated verbiage for submitting corrected claims, removed verbiage regarding reprocessed claims
PAP206 has been updated to clarify corrected claim submission requirements for Blue Cross of Idaho. The policy emphasizes electronic submission as the preferred method, specifies required claim frequency codes (5, 7, 8), mandates inclusion of the complete 12-digit claim number with attention to adjustment extensions, and prohibits resubmitting only denied line items. Key change: removed prior verbiage regarding reprocessed claims and added detailed instructions for both CMS 1500 (professional) and UB-04 (institutional) forms.
Blue Cross of Idaho · Effective Jul 1, 2026High impact
PAP206 - Submitting Corrected Claims - Clarification added for corrected claim submissions
Blue Cross of Idaho clarified corrected claim submission requirements effective July 2026, emphasizing mandatory use of specific claim frequency codes (5, 7, 8), inclusion of the complete 12-digit claim number with last two digits, and submission of entire claims rather than individual lines. Key clarification: submitting claims through the provider portal does not automatically identify them as corrected claims—providers must explicitly use the appropriate frequency code and original claim reference number.
Blue Cross of Idaho · Effective Jul 1, 2026High impact
PAP206 - Reprecessed and Corrected Claims - Added clarification regarding corrected claim submission requirements, claim replacement procedures, provider portal submissions, and hard copy claim submission instructions.
Blue Cross of Idaho clarified corrected claim submission requirements, emphasizing that providers must submit entire claims (not just corrected lines) using appropriate claim frequency codes (5, 7, or 8), include the full 12-digit claim number with original reference, and limit corrected submissions to one per day per claim. Portal submissions do not automatically identify claims as corrected, and electronic submission is the preferred method.
Humana · Effective Jul 1, 2026High impact
Breast Imaging - Medicare Advantage (Revised)
This is a revised Medicare Advantage policy for breast imaging (effective 07/01/2026) that establishes coverage criteria for mammography, digital breast tomosynthesis, breast MRI, and ultrasound. The policy clarifies medical necessity requirements and references applicable Local Coverage Determinations (LCDs) by MAC jurisdiction. Billing teams must verify which MAC jurisdiction applies to their geographic location to determine specific coverage rules.
Blue Cross of Idaho · Effective Jul 1, 2026High impact
PAP206 - Submitting Corrected Claims - Added additional instructions for submitting corrected claims
PAP206 has been revised to add clarification and additional instructions for submitting corrected claims to Blue Cross of Idaho. Key updates include explicit requirements for electronic submission using proper claim frequency codes (5, 7, 8), mandatory inclusion of the full 12-digit claim number with attention to the last two digits indicating adjustment history, and a prohibition on submitting multiple adjustments for the same claim on the same day. The policy also reinforces that providers must resubmit entire claims rather than individual lines to avoid claim recoupment errors.
PacificSource Health Plans · Effective Jun 22, 2026High impact
June 2026 Drug List Change Notification (Commercial)
PacificSource is implementing major formulary and prior authorization changes effective June 22, 2026, including 16 new drug additions across multiple tiers, removal of 5 standalone policies consolidated into broader categories, and state-specific formulary removals for OR/ID/MT/WA members. Billing teams must update systems to reflect new prior authorization requirements, quantity limits, step therapy rules, and limited access restrictions across numerous medications.
Blue Cross of Idaho · Effective Jun 1, 2026High impact
PAP510 - CPT Modifier 62 - Revised with reporting instructions.
Blue Cross of Idaho revised its CPT Modifier 62 policy (effective June 2026) to clarify co-surgeon billing requirements. Surgical procedures billed with modifier 62 are reimbursed at 62.5% of the maximum procedural allowance. The revision adds explicit reporting instructions requiring both co-surgeons to submit separate claims with their individual NPIs, identical CPT and diagnosis codes, and documentation supporting distinct surgical responsibilities.
SelectHealth · Effective Jun 1, 2026High impact
June 2026
Select Health published 6 policy changes including 2 new policies and 4 revisions. Major changes include discontinuation of Spravato coverage for commercial plans, new hyoid suspension coverage criteria for sleep apnea, and removal of cystoscopy requirements for sacral nerve stimulation. Additionally, 25 new genetic testing policies are being incorporated.
PacificSource Health Plans · Effective May 22, 2026High impact
May 2026 Drug List Change Notification (Commercial)
PacificSource updated its commercial drug formulary effective May 22, 2026, adding 10 new medications with tier 3 (or tier 4 in OR/ID/MT/WA) designations and various restrictions including prior authorization, quantity limits, and step therapy requirements. The update also retired the Fibrates policy due to drug discontinuation, modified prior authorization criteria for 13 drug classes, and removed 4 drugs from the formulary (Acyclovir solution, Megace ES suspension, Sitavig tablet, Triglide tablet).
PacificSource Health Plans · Effective Apr 9, 2026High impact
April 2026 Drug List Change Notification (Commercial)
PacificSource is implementing significant changes to GLP-1 receptor agonist prior authorization criteria, adding Tofidence as a tier 3 formulary drug with medical necessity requirements, updating quantity limits for Journavx Nurtec, and adding formulary exception criteria for Nurtec tablet across commercial plans and state-based drug lists (OR, ID, MT, WA). All changes are effective April 9, 2026.
UnitedHealthcare · Effective Apr 1, 2026High impact
Idaho Medicaid: New billing updates for diabetes equipment and supplies
Idaho Medicaid is moving billing for diabetes supplies and insulin administration equipment from medical benefit to pharmacy benefit effective April 1, 2026. During the transition period (Jan 1 - March 31, 2026), providers can bill either benefit, but after April 1st, all these codes must be billed through pharmacy or claims will be denied.
Blue Cross of Idaho · Effective Mar 1, 2026High impact
PAP224 - Place of Service - Removed Place of Service Codes Table
Blue Cross of Idaho revised PAP224 in March 2026 to clarify Place of Service (POS) coding rules for professional services. The policy now explicitly requires POS 11 for clinic services (regardless of hospital ownership), POS 22 or 23 for hospital outpatient/emergency services, and POS 21 for inpatient services. A previous POS codes table was removed in February 2022, requiring providers to reference the CPT book or the allowance calculation tool instead. Claims with incorrect or invalid POS codes will be denied by clinical editing software.
Blue Cross of Idaho · Effective Mar 1, 2026High impact
PAP224 - Place of Service - Added POS rules for outpatient.
Blue Cross of Idaho clarified Place of Service (POS) billing rules for outpatient services, effective March 2026. Providers must bill clinic services as POS 11 (office), hospital outpatient department services as POS 22 or 23, and inpatient services as POS 21. Incorrect POS codes will result in claim denials by clinical editing software, and POS selection may affect patient cost-sharing (deductible vs. copayment vs. percentage).
Blue Cross of Idaho · Effective Feb 1, 2026High impact
PAP518-Telehealth Virtual Care Services - Added clarification and reference to codes
Blue Cross of Idaho updated PAP518 to clarify telehealth billing requirements for employed providers at contracting clinics/facilities. Key change: employed telehealth providers must now be paid as employees and submit claims under the facility/clinic's tax ID and NPI, not their individual NPI. Additionally, the policy reinforces that PCPs cannot be telehealth-only providers and must provide periodic in-person services. Claims must use place-of-service codes 02 or 10 with appropriate modifiers (93, 95, GT, GQ, FR, FQ) based on delivery method.
Blue Cross of Idaho · Effective Feb 1, 2026High impact
PAP285 - AIM Specialty Health® Sleep Testing and Therapy - Updated website instructions
PAP285 updates Blue Cross of Idaho's prior authorization requirements for sleep testing and therapy services managed by Carelon. The policy clarifies that prior authorization is mandatory for all sleep diagnostic tests (HST, PSG), titration studies, and all therapy services (APAP, CPAP, BPAP, oral appliances) for commercial and Medicare Advantage members, with a 7-day retrospective authorization window and specific facility/provider credential requirements.
Blue Cross of Idaho · Effective Feb 1, 2026High impact
MAPAP217 - Telehealth Virtual Care Services - Updated to reflect requirements for contracting clinic employees.
Blue Cross of Idaho updated MAPAP217 to clarify that telehealth providers employed by contracting clinics or facilities must be paid as W-2 employees and submit all claims under the facility's/clinic tax identification number and NPI, not their individual provider NPI. This change affects how contracted telehealth services are billed and credentialed, effective February 2026.
Blue Cross of Idaho · Effective Jan 1, 2026High impact
PAP707 - Federal Employee Precertification and Prior Approval - Prior approval updated to add Skill Nursing Facility
PAP707 has been updated to add Skilled Nursing Facility (SNF) to the list of services requiring prior approval for Federal Employee Program (FEP) and U.S. Postal Service (USPS) Standard and Basic Option contracts, effective January 2026. Billing teams must now obtain prior approval before SNF admissions for these plan types to avoid claim denials.
Blue Cross of Idaho · Effective Jan 1, 2026High impact
MAPAP252 - Risk Adjustment Accuracy Program - New
Blue Cross of Idaho has updated its Risk Adjustment Accuracy (RAA) Program for 2026 performance metrics under Medicare Advantage value-based care arrangements. Participating providers must now track and meet specific targets for Annual Wellness Visit (AWV) rates and HCC Reconsideration rates, with performance measured quarterly (Q2) and year-end, using updated weighted calculations that determine performance levels 1-5.
Blue Cross of Idaho · Effective Dec 1, 2025High impact
MAPAP248 - Provider External Auditors - Added appeals must be handled through the vendor.
Blue Cross of Idaho has revised its policy for external auditor appeals - providers must now submit all inquiries and appeals related to vendor audit determinations directly to the vendor, not to Blue Cross of Idaho. Any appeals submitted to BCID will be rejected and returned with instructions to resubmit to the vendor.

Get alerts for changes like this

Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.

Create a free alert How Policy Monitoring works

Treatment of Temporomandibular Joint Disorders (for Idaho Only)

Surgery of the Shoulder (for Idaho Only)

December 2026 Drug List Change Notification (Commercial)

Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver (for Idaho Only)

Surgery of the Hip (for Idaho Only)

Obstructive and Central Sleep Apnea Treatment (for Idaho Only)

MP 5.01.28 Treatment for Spinal Muscular Atrophy - Concurrent use of risdiplam with onasemnogene abeparvovec-xioi and/or nusinersen is considered investigational.

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment Decisions (for Idaho Only)

Genetic Testing for Neurological Disorders (for Idaho Only)

Spinal Fusion and Decompression (for Idaho Only)

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

October 2026 Drug List Change Notification (Commercial)

MAPAP310 - Medicare Advantage Referral Requirements - Removed referral requirement and details per October 15, 2026, changes to only require referrals for out-of-network specialties services.

PAP313 - DRG Validation Review - New

PAP312 - Sepsis Clinical Validation and Reimbursement - New

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

Bariatric Surgery - Medicare Advantage (Revised)

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for Idaho Only)

Brow Ptosis and Eyelid Repair (for Idaho Only)

PAP281 - Provider External Auditors - Added appeals must be handled through the vendor.

Spinal Fusion Surgery - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)

Breast Reconstruction - Medicare Advantage (Revised)

Breast Excision and Mastectomy - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

MAPAP230 - Use of Modifiers - Updated modifier references for coding changes.

PAP206 - Submitting Corrected Claims - Updated verbiage for submitting corrected claims, removed verbiage regarding reprocessed claims

PAP206 - Submitting Corrected Claims - Clarification added for corrected claim submissions

PAP206 - Reprecessed and Corrected Claims - Added clarification regarding corrected claim submission requirements, claim replacement procedures, provider portal submissions, and hard copy claim submission instructions.

Breast Imaging - Medicare Advantage (Revised)

PAP206 - Submitting Corrected Claims - Added additional instructions for submitting corrected claims

June 2026 Drug List Change Notification (Commercial)

PAP510 - CPT Modifier 62 - Revised with reporting instructions.

June 2026

May 2026 Drug List Change Notification (Commercial)

April 2026 Drug List Change Notification (Commercial)

Idaho Medicaid: New billing updates for diabetes equipment and supplies

PAP224 - Place of Service - Removed Place of Service Codes Table

PAP224 - Place of Service - Added POS rules for outpatient.

PAP518-Telehealth Virtual Care Services - Added clarification and reference to codes

PAP285 - AIM Specialty Health® Sleep Testing and Therapy - Updated website instructions

MAPAP217 - Telehealth Virtual Care Services - Updated to reflect requirements for contracting clinic employees.

PAP707 - Federal Employee Precertification and Prior Approval - Prior approval updated to add Skill Nursing Facility

MAPAP252 - Risk Adjustment Accuracy Program - New

MAPAP248 - Provider External Auditors - Added appeals must be handled through the vendor.