What insurance policy changes affect Indiana providers?

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

How often are Indiana 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 Indiana insurance policy changes?

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

PAYER POLICY CHANGES

Indiana Insurance & Medicaid Policy Updates

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

UnitedHealthcare · Effective Dec 1, 2026High impact
Erythropoiesis-Stimulating Agents
UnitedHealthcare Community Plan of Indiana revised its Medicaid Erythropoiesis-Stimulating Agents medical benefit drug policy, effective 2026-12-01. Coverage criteria now use "ESAs" as the umbrella term for all listed agents, treat each hematocrit value as either pretreatment (first 4-6 weeks) or on-treatment monitoring, and use a hemoglobin-to-hematocrit conversion factor of 3 when only hemoglobin is measured. The policy also removes language stating it does not apply to Indiana.
Indiana Medicaid (IHCP) · Effective Dec 1, 2026High impact
BT2026176: IHCP announces updates and corrections to physical and occupational therapy codes
IHCP is requiring modifier GP or GO on prior authorization requests and claims for CPT code 97150 (group therapy) effective December 1, 2026, retroactive to January 1, 2025, to distinguish between physical therapy (GP) and occupational therapy (GO) services. Additionally, CPT code 97542 is being added to the modifier-match requirement table (effective August 19, 2024), and CPT code 92610 is being removed from the table.
UnitedHealthcare · Effective Dec 1, 2026High impact
Treatment of Temporomandibular Joint Disorders (for Indiana Only)
UnitedHealthcare Community Plan of Indiana is removing coverage for four CPT codes (21060, 21247, 29800, 29804) related to temporomandibular joint disorder treatment, effective December 1, 2026. Indiana Medicaid providers must stop billing these codes and identify alternative treatment pathways for affected patients.
UnitedHealthcare · Effective Dec 1, 2026High impact
Obstructive and Central Sleep Apnea Treatment (for Indiana Only)
UnitedHealthcare Community Plan of Indiana revised its sleep apnea treatment policy effective December 1, 2026, adding radiofrequency ablation of soft palate/tongue base to the list of unproven procedures, updating applicable HCPCS codes (including new code L8697), and clarifying coverage criteria for surgical and nonsurgical treatments including orthognathic surgery, UPPP, and hypoglossal nerve stimulation with specific age and clinical parameters.
CareSource · Effective Dec 1, 2026High impact
[Indiana] Cardiac and Musculoskeletal Surgical Quality and Safety Management Program in Partnership with TurningPoint
Effective December 1, 2026, CareSource is expanding TurningPoint's Cardiac and Musculoskeletal Surgical Quality and Safety Management Program to Indiana Medicaid members (Healthy Indiana Plan and Hoosier Healthwise). Prior authorization is now REQUIRED for all cardiac surgeries and musculoskeletal/orthopedic procedures listed in the policy before service delivery. Claims without prior authorization will be denied.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem Medicare Advantage is implementing a new reimbursement policy effective December 1, 2026, that prohibits pass-through laboratory billing (modifier 90) for professional and outpatient facility providers, requiring them to bill directly instead. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and has been consolidated into this new combined policy.
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
[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.
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Effective December 1, 2026, Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for laboratory services billed with modifier 90 (pass-through billing). Providers must bill directly for laboratory services and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and is consolidated into this new policy. The prior modifier 91 policy (G-06020) is being retired.
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
BT2026180: IHCP announces updates to maternity codes due to nationally recognized changes
Starting Jan. 1, 2027, Indiana Medicaid (IHCP) will follow the AMA's revised CPT maternity codes, and the current maternity codes will no longer be valid for dates of service on or after that date. The IHCP will no longer accept global or bundled maternity billing on any claim, including when billed as secondary, so prenatal care, labor management, delivery and postpartum care must each be billed with the appropriate codes. Prenatal and postpartum visits will be billed as E/M codes with modifier TH and the trimester or postpartum modifier, and the new labor management and delivery codes replace the discontinued ones.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027High impact
BT2026168: IHCP updates billing requirements for retroactive Healthy Indiana Plan eligibility
Beginning January 1, 2027, Indiana HIP members approved for retroactive coverage will be assigned to a new FFS aid category (RH) for retroactive months instead of managed care. Providers must verify eligibility through EVS, submit retroactive claims directly to Gainwell Technologies (the IHCP fiscal agent) rather than to MCOs, and continue billing MCOs for current/prospective months. An exception applies if the member had HIP coverage end within the preceding 90 days.
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.
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.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027High impact
BT2026143: IHCP announces changes to the Professional Fee Schedule and anesthesia conversion factor for 2027
Indiana Health Coverage Programs (IHCP) is updating its Professional Fee Schedule effective January 1, 2027, to reflect 100% of Medicare's 2026 fee schedule rates for physician services, DME, medical supplies, and transportation services. The anesthesia conversion factor will change to $19.58. Certain services (ABA therapy, dental, home health, HCBS waiver, MRO, and 21st Century Cures Act DME codes) are excluded from these changes. MCOs must align their fee schedules by January 1, 2027.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027High impact
BT2026125: IHCP recognizes maternity procedure code changes, effective Jan. 1, 2027
Effective January 1, 2027, the American Medical Association is replacing traditional global obstetrical bundles with separate CPT codes for distinct maternity services (prenatal care, labor management, labor/delivery, and postpartum care). IHCP will recognize these new codes, representing a shift from bundled to unbundled billing. Additional policy guidance from IHCP is forthcoming.
Indiana Medicaid (IHCP) · Effective Oct 1, 2027High impact
BT2026118: IHCP reminds ABA agencies of accreditation requirement
IHCP requires all Applied Behavior Analysis (ABA) agencies to obtain accreditation from ACQ or BHCOE. Currently enrolled ABA providers must submit documentation of accreditation initiation by August 1, 2026, and must complete full accreditation by October 1, 2027, or their IHCP enrollment will be deactivated.
Indiana Medicaid (IHCP) · Effective Oct 1, 2027High impact
BT202646: IHCP to require ABA agencies to be accredited
Starting October 1, 2027, all ABA agencies in Indiana must be accredited by ACQ or BHCOE to remain enrolled with IHCP. Currently enrolled agencies must submit documentation showing they've initiated accreditation by August 1, 2026, or face deactivation.
Indiana Medicaid (IHCP) · Effective Nov 13, 2026Medium impact
BT2026169: IHCP to allow reimbursement of PTA-rendered G0238
Effective November 13, 2026, Indiana Health Coverage Programs (IHCP) will allow Physical Therapist Assistants (PTAs) to perform and bill HCPCS code G0238 (therapeutic procedures to improve respiratory function) under supervising practitioner supervision. PTA-rendered services must be billed with the supervising practitioner's NPI, modifier HM appended, and will be reimbursed at 75% of the IHCP fee schedule. This change applies to both managed care and fee-for-service medical benefits.
Indiana Medicaid (IHCP) · Effective Nov 30, 2026Medium impact
BT2026185: IHCP updates Emergency Services Only billing requirements
Beginning November 30, 2026, the Indiana Health Coverage Programs (IHCP) requires all fee-for-service professional claims for Emergency Services Only (ESO) coverage to include an approved emergency or labor/delivery diagnosis in the primary position AND have the emergency indicator field marked on the claim for each service detail. This affects qualifying non-U.S. citizens enrolled in ESO Coverage with Pregnancy Coverage (Package B) or Emergency Services Only (Package E).
Indiana Medicaid (IHCP) · Effective Nov 30, 2026Medium impact
BT2026177: IHCP updates inpatient claim processing for emergency admissions
Effective November 30, 2026, Indiana's Medicaid FFS system will no longer deny emergency inpatient claims (admission type 1) when the from date of service precedes the admission date by three days or less. Previously, these claims were rejected with EOB code 0519. Gainwell will automatically reprocess affected claims; providers need not resubmit.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Omalizumab
Effective 2026-12-01, UnitedHealthcare Community Plan of Indiana (Medicaid) revised its omalizumab medical benefit drug policy, retitling it from Xolair to omalizumab and covering Omlyclo (omalizumab-igec), Xolair, and any FDA-approved, launched omalizumab biosimilar. Biosimilars not named in the policy are considered non-preferred until UnitedHealthcare reviews them, and HCPCS code Q5154 was added. Self-administered omalizumab is obtained under the pharmacy benefit rather than the medical benefit.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Maximum Dosage and Frequency
UnitedHealthcare Community Plan of Indiana revised its Maximum Dosage and Frequency medical benefit drug policy for Medicaid members in Indiana, updating the list of maximum allowed quantities and frequencies by HCPCS units and adding Exdensur (depemokimab) and Spinraza (nusinersen). Billing teams should update charge entry and claim edits for these drugs so units and administration frequency stay within the stated limits, and add HCPCS J2326 and J2361 to the applicable code set.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Intravenous Iron Replacement Therapy (Feraheme ® , Injectafer ® , & Monoferric ® )
UnitedHealthcare Community Plan of Indiana revised its Medicaid medical policy for Feraheme (ferumoxytol), Injectafer (ferric carboxymaltose), and Monoferric (ferric derisomaltose). Coverage is now described as proven for iron deficiency anemia without CKD and for iron deficiency anemia with CKD but without ESRD, and Injectafer is covered for iron deficiency in adults with NYHA class II/III heart failure to improve exercise capacity when all listed criteria are met; the policy also adds definitions and ICD-10 codes for these indications and removes the language excluding Indiana.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease
UnitedHealthcare Community Plan of Indiana revised its Medicaid medical policy for intravenous enzyme replacement therapy for Gaucher disease, effective 2026-12-01. VPRIV, Cerezyme, and Elelyso are covered as medically necessary for type 1 Gaucher disease when the listed criteria are met, VPRIV or Cerezyme for type 3 under the listed criteria, and all three are unproven and not medically necessary for type 2, with Elelyso also unproven for type 3. The change also adds ICD-10 code E75.22 to the applicable codes.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Ilaris ® (Canakinumab)
UnitedHealthcare Community Plan of Indiana revised its Ilaris (canakinumab) medical benefit drug policy for Indiana Medicaid members, effective 2026-12-01. Coverage is now stated for CAPS (including FCAS and MWS), TRAPS, HIDS/MKD, FMF (after colchicine failure, contraindication or intolerance), and active Still's disease (AOSD and SJIA), each with initial and continuation criteria and authorization periods of no more than 12 months, and the policy adds a list of applicable ICD-10 diagnosis codes; the Indiana-exclusion language was also removed.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Edaravone
UnitedHealthcare Community Plan of Indiana revised its Edaravone medical benefit drug policy for Medicaid members, effective 2026-12-01. Edaravone for amyotrophic lateral sclerosis (ALS) is now stated as proven and medically necessary for patients who meet listed criteria, and the Indiana exclusion language was removed. Practices prescribing or billing edaravone for ALS should confirm the documentation and authorization elements before that date.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Alpha1-Proteinase Inhibitors
Effective 2026-12-01, the UnitedHealthcare Community Plan of Indiana Medicaid medical benefit drug policy for Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) now covers these products as proven and medically necessary for chronic augmentation and maintenance therapy in patients with emphysema due to congenital alpha1-antitrypsin deficiency, with initial authorization and reauthorization each limited to no more than 12 months. The policy also removes language saying it did not apply to Indiana, adds ICD-10 code E88.01, and continues to list cystic fibrosis and conditions other than AAT-associated emphysema as unproven.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease
UnitedHealthcare Community Plan updated its Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease medical policy in its November 2026 bulletin, with an effective date of 2026-12-01. The update removed language that had excluded Indiana from the policy's application, so the policy now applies to Indiana Medicaid members as well.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Ilaris ® (Canakinumab)
Effective 2026-12-01, UnitedHealthcare's Community Plan Medicaid medical policy for Ilaris (canakinumab) drops the prior exclusion for Indiana and adds a rule that members with active Still's disease, including adult-onset Still's disease (AOSD) and systemic juvenile idiopathic arthritis (SJIA), must not be receiving Ilaris together with another systemic targeted immunomodulator for the same indication. Billing staff should confirm that Indiana Medicaid claims for Ilaris for these indications are now processed under this policy and check that prior auth and documentation for these members reflect that no concurrent systemic targeted immunomodulator is being used for the same indication.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Erythropoiesis-Stimulating Agents
UnitedHealthcare's Community Plan Medicaid Medical Benefit Drug Policy for Erythropoiesis-Stimulating Agents was updated in the November 2026 bulletin, with a listed effective date of December 1, 2026. The change removes language that had excluded Indiana from the policy, so claims for Indiana Community Plan Medicaid members receiving these agents now fall under this policy.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Edaravone
UnitedHealthcare Community Plan updated its Medical Benefit Drug Policy for Edaravone in the November 2026 bulletin, with the change effective 2026-12-01. The revision removes language that had excluded Indiana from the policy, so Indiana Community Plan claims for Edaravone are now governed by this policy.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Alpha1-Proteinase Inhibitors
UnitedHealthcare's Community Plan Medicaid medical policy for Alpha1-Proteinase Inhibitors was updated in the November 2026 bulletin, effective 2026-12-01. The change removes language that had excluded Indiana from this Medical Benefit Drug Policy, so the policy now applies to Indiana Community Plan Medicaid members.
CareSource · Effective Dec 1, 2026Medium impact
[Indiana] October 2026 Policy Updates
CareSource Indiana Medicaid is releasing 13 policy updates effective December 1, 2026, spanning medical, administrative, and reimbursement categories. Changes include new policies for Speech Generating Devices, Newborn/NICU Level of Care, EKG Interpretations, and Postpayment Review procedures, along with revisions to existing policies covering clinical trials, pain management, behavioral health documentation, coding guidelines, and claims editing. None of these changes impact prior authorization requirements.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Saphnelo® (Anifrolumab-Fnia)
Effective 2027-01-01, UnitedHealthcare Community Plan of Indiana (Medicaid) revised its Saphnelo (anifrolumab-fnia) medical benefit drug policy. For initial and continuing IV Saphnelo coverage, the prescriber must now attest that the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta, with a written explanation, and must document a history of failure, contraindication, or intolerance to Benlysta IV or SQ for initial therapy. Saphnelo is considered unproven and not medically necessary for severe active lupus nephritis, severe active CNS lupus, and combination use with other biologics.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
FcRn Blockers
UnitedHealthcare Community Plan of Indiana revised its FcRn Blockers medical benefit drug policy, effective 2027-01-01, to add coverage language for Imaavy (nipocalimab-aahu) in treating warm autoimmune hemolytic anemia (wAIHA) in adults and pediatric patients 12 years and older who have been treated with corticosteroids. Coverage requires documented diagnosis, prior corticosteroid, immunosuppressant or rituximab history, hematologist involvement, and no concurrent rituximab or immune globulin; ICD-10 code D59.11 was added.
CareSource · Effective Jan 1, 2027Medium impact
[Indiana] November 2026 Policy Updates
CareSource Indiana Medicaid is introducing a new medical policy for Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (Policy MM-1869) effective January 1, 2027. This new policy does not impact prior authorization requirements. Billing teams should review the full policy details on CareSource's provider portal to understand coverage criteria and any documentation requirements for ABA services.
CareSource · Effective Jan 1, 2027Medium impact
[Indiana] November 2026 Pharmacy Policy Updates
CareSource Indiana Medicaid released 21 pharmacy policy updates effective January 1, 2027, affecting specialized medications across multiple therapeutic categories (rare diseases, ophthalmology, pulmonology, hematology, and others). The updates include 14 revised policies, 3 new policies, 1 annual review, and 1 archived policy. None of the changes impact prior authorization requirements.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027Medium impact
BT2026183: FFS providers using Atrezzo portal will receive PA notification letters in portal beginning Jan. 1, 2027
Beginning January 1, 2027, FFS providers using the Atrezzo Provider Portal will receive all prior authorization notification letters electronically through the portal instead of by mail. Email notifications will alert providers when determinations are available, with case IDs provided for reference; providers must log into Atrezzo to view full letters. Training webinars will be offered in November and December 2026.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027Medium impact
BT2026184: Pharmacy updates approved by Drug Utilization Review Board October 2026
Indiana Health Coverage Programs bulletin BT2026184 announces pharmacy updates approved by the Drug Utilization Review Board at its October 16, 2026 meeting. The updates cover the Point of Sale Quick Check automated prior authorization system, prior authorization criteria for several drug classes, the Statewide Uniform Preferred Drug List (SUPDL), the Preferred Brand Drug List and the Preferred HIV Agents List. The prior authorization changes apply to requests submitted on or after January 1, 2027, and the SUPDL, Preferred Brand Drug List and Preferred HIV Agents List changes apply to fee-for-service and managed care claims with dates of service on or after January 1, 2027.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027Medium impact
BT2026178: IHCP updates prior authorization guidance for CCBHC MRO-equivalent services
Indiana Health Coverage Programs (IHCP) is updating the prior authorization process for Medicaid Rehabilitation Option (MRO)-equivalent services provided by certified community behavioral health clinics (CCBHCs). Starting January 1, 2027, the state will automatically generate Level of Need (LON) 4 service authorizations for CCBHC clients with MRO-eligible diagnoses, eliminating the need for manual prior authorization requests for default LON 4 coverage. Providers must request higher LON authorizations (LON 5 or 6) by December 31, 2026, or clients will default to LON 4.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027Medium impact
BT2026108: IHCP announces HIP work requirements resources
Starting January 1, 2027, Healthy Indiana Plan (HIP) members must complete 80 hours of work or community engagement monthly to maintain coverage, unless exempt. Provider resources and toolkits will be available at myfssa.in.gov beginning July 6, 2026.
Anthem BCBS · Effective Feb 1, 2027Medium impact
[New York] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility
Effective February 1, 2027, Anthem will stop separately reimbursing moderate sedation services (revenue codes 0371 and 0372) on inpatient facility claims when reported with room and board charges for Commercial plans in New York and eight other states. Practices must stop billing these codes separately on inpatient UB-04 claims for Anthem members, as payment is now bundled into room and board reimbursement.
Anthem BCBS · Effective Feb 1, 2027Medium impact
[Georgia] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility
Effective February 1, 2027, Anthem will no longer separately reimburse moderate sedation services (revenue codes 0371 and 0372) on inpatient facility claims when reported with room and board charges; reimbursement is now bundled into room and board payment. Billing teams must stop billing these codes separately on inpatient UB-04 claims for Anthem Commercial members in Georgia and other affected states.
Indiana Medicaid (IHCP) · Effective Oct 1, 2027Medium impact
BT202660: IHCP clarifies ABA accreditation requirement
IHCP clarifies that ABA providers must have accredited service lines in each state where they operate, with specific notification requirements to ACQ for location changes and operational updates. This requirement takes effect October 1, 2027 for all newly enrolled and existing ABA group enrollments.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Pasatru™ (Garetosmab-Grts)
Starting with services dated on or after December 1, 2026, UnitedHealthcare Community Plan of Indiana Medicaid members who receive Pasatru (garetosmab-grts) for fibrodysplasia ossificans progressiva must meet new medical benefit drug criteria. Initial therapy requires patients over 18, an FOP diagnosis, chart notes documenting clinical signs and symptoms, and genetic testing confirming an ACVR1 mutation, with prescribing by or in consultation with an FOP expert, dosing per FDA labeling, no combination with Sohonos (palovarotene), and initial authorization of no more than 12 months. Continuation requires documented positive clinical response and the same exclusions, with reauthorization of no more than 12 months.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)
UnitedHealthcare Community Plan of Indiana added a new medical benefit drug policy for Genglycos (pariglasgene brecaparvovec-opnr), covering treatment of glycogen storage disease type Ia for patients 8 years and older. Coverage requires confirmed diagnosis (bi-allelic G6PC variants or absent G6Pase activity on liver biopsy), current cornstarch therapy, no detectable AAV8 antibodies, no prior gene therapy, prescribing or consultation by a metabolic specialist, no planned inpatient admission solely for administration, dosing per FDA labeling, and authorization limited to one lifetime treatment and no more than 45 days from approval.
CareSource · Effective Dec 1, 2026Low impact
[Indiana] October 2026 Pharmacy Policy Update
CareSource Indiana Medicaid has issued a revised pharmacy policy (IN-MED-P-5901950-V.1) effective December 1, 2026, regarding Medical Benefit Medications. The policy revision does not introduce new prior authorization requirements. This is a routine policy update maintaining CareSource's monthly cycle for consolidated pharmacy policy notifications.

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Erythropoiesis-Stimulating Agents

BT2026176: IHCP announces updates and corrections to physical and occupational therapy codes

Treatment of Temporomandibular Joint Disorders (for Indiana Only)

Obstructive and Central Sleep Apnea Treatment (for Indiana Only)

[Indiana] Cardiac and Musculoskeletal Surgical Quality and Safety Management Program in Partnership with TurningPoint

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

[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

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

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

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

BT2026180: IHCP announces updates to maternity codes due to nationally recognized changes

BT2026168: IHCP updates billing requirements for retroactive Healthy Indiana Plan eligibility

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

New oncology prior authorization code updates

BT2026143: IHCP announces changes to the Professional Fee Schedule and anesthesia conversion factor for 2027

BT2026125: IHCP recognizes maternity procedure code changes, effective Jan. 1, 2027

BT2026118: IHCP reminds ABA agencies of accreditation requirement

BT202646: IHCP to require ABA agencies to be accredited

BT2026169: IHCP to allow reimbursement of PTA-rendered G0238

BT2026185: IHCP updates Emergency Services Only billing requirements

BT2026177: IHCP updates inpatient claim processing for emergency admissions

Omalizumab

Maximum Dosage and Frequency

Intravenous Iron Replacement Therapy (Feraheme ® , Injectafer ® , & Monoferric ® )

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

Ilaris ® (Canakinumab)

Edaravone

Alpha1-Proteinase Inhibitors

Intravenous Enzyme Replacement Therapy (ERT) for Gaucher Disease

Ilaris ® (Canakinumab)

Erythropoiesis-Stimulating Agents

Edaravone

Alpha1-Proteinase Inhibitors

[Indiana] October 2026 Policy Updates

Saphnelo® (Anifrolumab-Fnia)

FcRn Blockers

[Indiana] November 2026 Policy Updates

[Indiana] November 2026 Pharmacy Policy Updates

BT2026183: FFS providers using Atrezzo portal will receive PA notification letters in portal beginning Jan. 1, 2027

BT2026184: Pharmacy updates approved by Drug Utilization Review Board October 2026

BT2026178: IHCP updates prior authorization guidance for CCBHC MRO-equivalent services

BT2026108: IHCP announces HIP work requirements resources

[New York] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility

[Georgia] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility

BT202660: IHCP clarifies ABA accreditation requirement

Pasatru™ (Garetosmab-Grts)

Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)

[Indiana] October 2026 Pharmacy Policy Update