What insurance policy changes affect Minnesota providers?

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

How often are Minnesota 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 Minnesota insurance policy changes?

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

PAYER POLICY CHANGES

Minnesota Insurance & Medicaid Policy Updates

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

Blue Cross and Blue Shield of Minnesota · Effective Dec 1, 2026High impact
Upcoming Policies effective December 1, 2026
Blue Cross Minnesota is inactivating 12 medical policies effective December 1, 2026, primarily affecting laboratory testing, genetic screening, and diagnostic panels (Barrett's Esophagus surveillance, cardiovascular risk biomarkers, substance use drug testing, cancer genetic panels, vitamin D screening, and others). The billing team must identify all claims currently billed under these policy numbers and determine replacement coverage guidance or discontinue billing for these services.
HealthPartners · Effective Jan 1, 2027High impact
Fast Facts Newsletter - November 2026
HealthPartners' November 2026 Fast Facts newsletter lists several changes, most effective January 1, 2027: Cigna-insured members will require precertification for outpatient non-emergency CT, MRI and PET imaging; manual and power mobility device codes will require prior authorization for Medicare Advantage, Medicare Cost and MSHO members; Actemra is being replaced by the biosimilar Avtozma and several diabetes and insulin drugs are leaving the formulary; and Minnesota Medicaid moves to MNAAC pharmacy reimbursement. The billing team should also note the standing reminder to submit any change to a previously filed claim as a corrected claim with Bill Frequency Code 7.
Blue Cross and Blue Shield of Minnesota · Effective Jan 4, 2027High impact
Upcoming Policies effective January 4, 2027
Blue Cross Minnesota revised its medical policy for Applied Behavior Analysis (ABA) assessment and early intensive behavioral intervention for autism spectrum disorder, effective January 4, 2027. The policy establishes new clinical criteria for medical necessity, including required diagnostic and adaptive behavioral assessments, functional behavioral assessment completion, treatment plan specifications, supervision ratios, and ongoing authorization requirements with validated assessment tool documentation every 6 months.
Minnesota Medicaid (MHCP) · Effective Jan 1, 2028Medium impact
Single pharmacy benefit manager update
Minnesota Department of Human Services has contracted with Prime Therapeutics as the single pharmacy benefit manager (sPBM) to administer outpatient pharmacy benefits for Minnesota Health Care Programs members in managed care plans, effective January 1, 2028. Billing teams must prepare for a transition in how pharmacy claims are processed and routed for these plans, separate from the existing fee-for-service program.
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.
Blue Cross and Blue Shield of Minnesota · Effective Sep 7, 2026High impact
Upcoming Policies effective September 7, 2026
Blue Cross Minnesota has revised spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation coverage policy effective September 7, 2026, establishing stricter medical necessity criteria for trial and permanent implants, including mandatory 6-month conservative management, psychological evaluation, and 6-week smoking cessation requirements. A new policy classifies implantable knee shock absorbers as experimental/investigative. The policy on Psychological and Neuropsychological Testing (X-45) has been inactivated.
Aetna · Effective Sep 1, 2026High impact
OfficeLink Updates - June 2026 newsletter
Aetna is implementing multiple billing and operational changes effective September 1, 2026, including new claim edits through the Claim and Code Review Program (CCRP) and a 15% payment reduction for certain radiology services billed with modifier CT. Additionally, commercial drug lists will be updated October 1, 2026, and providers must maintain current credentialing contact information to avoid removal from the directory.
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 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
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.
Minnesota Medicaid (MHCP) · Effective Aug 1, 2026High impact
Provider signature requirements for HCBS members support plans
Minnesota DHS updated HCBS support plan signature requirements effective August 1, 2026, clarifying that all providers serving HCBS waiver members, Alternative Care (AC), and Essential Community Supports (ECS) members must sign and retain current copies of support plans. Failure to comply may result in claims nonpayment or payment takebacks.
HealthPartners · Effective Jul 1, 2026High impact
Fast Facts Newsletter - May 2026
HealthPartners' May 2026 Fast Facts newsletter (a historical issue first detected 2026-11-06) lists many medical, pharmacy, and utilization-management policy updates, most with a 07/01/2026 effective date that has already passed relative to the analysis date. Key billing-relevant items include new or revised prior-authorization requirements for specific oncology, cardiology, endocrine, genetic, and imaging tests and for certain CPT codes under Cohere Health criteria (CPT 70471, 70472, 70473), plus formulary moves that shift some drugs to the medical benefit with prior authorization. The practice should verify current applicability of each item rather than treat these as pending deadlines.
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.
Minnesota Medicaid (MHCP) · Effective Jul 1, 2026High impact
Changes to Substance Use Disorder (SUD) treatment services
Minnesota is implementing legislative changes to Substance Use Disorder (SUD) treatment services effective July 1, 2026. These changes include new service type descriptions, new billing codes, and new billing procedures for outpatient SUD providers. The changes are pending federal approval and require preparation time before implementation.
Minnesota Medicaid (MHCP) · Effective Jun 12, 2026High impact
CMS Managed Care Plan audit and record requests for EIDBI and peer recovery services providers
The Minnesota Department of Human Services is conducting a CMS Managed Care Plan audit of EIDBI and peer recovery services providers. CoventBridge Group is the authorized vendor requesting medical and administrative records on behalf of CMS. Healthcare practices must comply with all record requests and meet specified deadlines provided by CoventBridge Group.
Minnesota Medicaid (MHCP) · Effective May 20, 2026High impact
Early Intensive Developmental and Behavioral Intervention (EIDBI) claim denials for services billed with CPT code H0046 UB resolved
Minnesota Health Care Programs (MHCP) has resolved a system issue that incorrectly denied EIDBI claims billed with CPT code H0046 UB for dates of service from Dec. 16, 2025 through Jan. 27, 2026. Affected providers can either allow DHS to reprocess claims automatically or submit manual rebills. Billing teams should identify impacted claims and take action to recover denied revenue.
Minnesota Medicaid (MHCP) · Effective Apr 29, 2026High impact
Update on H0032 and H0046 reimbursement rates for EIDBI services
Minnesota Health Care Programs (MHCP) corrected an underpayment issue affecting EIDBI service codes H0046 UB (Travel Time) and H0032 UB (Individual Treatment Planning and Progress Monitoring) for claims billed March 25–April 28, 2026. Reimbursement rates are now correct as of April 29, 2026. Providers with impacted claims can request DHS reprocessing or submit replacement claims.
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.
HealthPartners · Effective Feb 1, 2026High impact
Fast Facts Newsletter - December (Special Edition) 2025
HealthPartners is implementing a new refund recovery process that will show credit balances on provider accounts and generate Negative Vendor letters instead of standard remits. Multiple medical policy updates take effect immediately or February 1, 2026, including changes to SNF criteria, inpatient care guidelines, and various coverage policies.
Minnesota Medicaid (MHCP) · Effective Feb 1, 2026High impact
2026 Mental Health Codes and Maximum Adjusted Fee For Service (FFS) Rate by Date of Rate Change grid published
Minnesota Department of Human Services published updated Mental Health Codes and Maximum Adjusted Fee-for-Service (FFS) rates effective February 1, 2026. Billing teams must review the new rate grid and Page 1 guidance to understand when services qualify for adjusted reimbursement rates, as this supersedes previous mental health rate schedules.
HealthPartners · Effective Jan 1, 2026High impact
Fast Facts Newsletter - November 2025
HealthPartners' November 2025 Fast Facts newsletter (a historical document, issued 2025-11-01 and first detected 2026-11-06) lists multiple provider-relations, pharmacy, and medical coverage policy updates, most with effective dates of 1/1/2026 or 11/1/2025. For billing teams, the most claim-relevant items are new or revised prior authorization requirements for acute inpatient rehabilitation and long-term acute care hospitalization (Commercial and Minnesota Health Care Programs; Medicare Advantage for acute inpatient rehabilitation), changes to coverage criteria for several lab and genetic test families, and expanded or retired coverage for specific services. Because the source's dates for these changes have already passed relative to the 2026-11-06 analysis date, the team should verify current applicability with HealthPartners rather than treat them as pending deadlines.
HealthPartners · Effective Jan 1, 2026High impact
Fast Facts Newsletter - January 2026
HealthPartners' January 2026 Fast Facts newsletter reports several provider-facing changes: pharmacy claims administration moving to Express Scripts effective January 1, 2026; commercial drug formulary replacements (Humira/Hadlima, Lantus, Ventolin HFA) with biosimilar or generic alternatives; new and revised medical coverage policies (including non-covered services added and aquablation for BPH criteria changed) Reported as already effective in the historical source as of 01/01/2026; and a reminder that providers must not bill QMB members for Medicare Part A/B cost sharing. Because the source is dated 2026-01-01 and the analysis date is 2026-11-06, these items are historical; billing staff should verify current applicability in the live formulary and coverage policies rather than treat them as pending deadlines.
Minnesota Medicaid (MHCP) · Effective Jan 1, 2026High impact
Jan. 1, 2026, PCA and CFSS reimbursement rates and wage floor retroactive payment requirements
Minnesota DHS has implemented new tiered minimum wage floors for Personal Care Assistance (PCA) and Community First Services and Supports (CFSS) direct support workers, effective Jan. 1, 2026, with retroactive payment requirements. Providers must pay workers the enhanced minimum wages for all hours worked from Jan. 1, 2026 forward, and must make retroactive payments for hours already worked. New wage floor tiers were distributed to PCA Choice and FMS providers on May 28, 2026.
HealthPartners · Effective Aug 1, 2025High impact
Fast Facts Newsletter - June (Special Edition) 2025
This June 2025 HealthPartners Fast Facts special edition (historical, issued 2025-06-01 and first detected 2026-11-06) reports a Minnesota Health Care Programs weight-loss medication PA criteria update (Saxenda, Wegovy, Zepbound) requiring lifestyle-modification criteria and chart documentation of medical visit discussions, plus a Herceptin Hylecta non-preferred addition for new starts. It also announces advanced imaging prior authorization through Cohere Health effective 8/1/2025 for CT, CTA, MRA, MRI, MRCP and PET across Fully Insured Commercial, Self-Insured Level Funded, Medicare Advantage and Minnesota Health Care Programs plans. Because the 8/1/2025 date has already passed relative to the analysis date, billing teams should verify current applicability with HealthPartners rather than treat it as pending.
HealthPartners · Effective Aug 1, 2025High impact
Fast Facts Newsletter - June (Special Edition) 2025
HealthPartners is implementing new prior authorization requirements for advanced imaging services (CT, CTA, MRA, MRI, PET) through Cohere Health effective August 1, 2025, and adding new psychotherapy services reimbursement policies. Weight loss medication PA criteria are also being updated with stricter documentation requirements.
Blue Cross and Blue Shield of Minnesota · Effective Jul 7, 2025High impact
Upcoming Policies effective July 7, 2025
Blue Cross Minnesota revised their cervical spinal fusion policy (IV-181) with stricter medical necessity criteria including mandatory 6-week smoking cessation requirements and specific conservative treatment protocols. They also added coverage for absorbable perirectal spacers during prostate cancer radiotherapy and inactivated the hippotherapy policy.
HealthPartners · Identified Nov 6, 2026High impact
Fast Facts Newsletter - January 2025
HealthPartners' January 2025 Fast Facts newsletter (a historical source, published 2025-01-01 and first detected 2026-11-06) bundles many provider notices: directory verification, rendering-provider submission requirements, EIDBI behavior analyst licensure requirements effective 1/1/2025, several medical coverage policy revisions (genetic testing, gender-affirming care, prosthetics, varicose vein procedures with a 3/1/2025 date, MCG criteria), pharmacy formulary and policy changes, and MHCP/MSHO/QMB reminders. Items with past effective dates (e.g., 1/1/2025 and Current applicability review-effective revisions) should be treated as already in effect and checked against current applicability, while items dated 3/1/2025 or later were future at publication and have now elapsed or should be verified for current status.
HealthPartners · Identified Nov 6, 2026High impact
Fast Facts Newsletter - May 2025
HealthPartners' May 2025 Fast Facts newsletter lists several provider-facing changes, most with an effective date of 7/1/2025, including new or revised medical coverage policies, a Cohere Health prior authorization requirement for certain cardiovascular and musculoskeletal services for Level Funded Self-Insured Commercial plans, and Medicare prior authorization for deep brain stimulation for essential tremor and Parkinson's disease and for phrenic nerve stimulation. This is a historical newsletter first detected 2026-11-06; the 7/1/2025 dates have already passed, so the billing team should verify current applicability in the HealthPartners portal and coverage criteria rather than treat these as pending.
HealthPartners · Identified Nov 6, 2026High impact
Fast Facts Newsletter - February (Special Edition) 2026
HealthPartners' February 2026 special-edition provider newsletter (source issue date 2026-02-01, first detected 2026-11-06, so historical) lists many pharmacy and medical policy changes across Commercial, Minnesota Health Care Programs and Medicare plans, including new or expanded prior authorization for somatostatin analogues, oncology drugs, Krystexxa and prostaglandin intracameral implants, formulary removals (Austedo, Ventolin), Medicare Part B step-therapy preferences, and dated medical policy revisions (spinal cord stimulation, RFA denervation, breast surgery, home health InterQual criteria, Cohere criteria) effective 04/01/2026, which has already passed and should be checked for current applicability. The billing team should use the source's plan- and product-specific notes to update prior authorization steps, charge entry and provider communication for affected services.
HealthPartners · Identified Nov 6, 2026High impact
Fast Facts Newsletter - July 2026
HealthPartners' July 2026 Fast Facts newsletter (published 2026-07-01, first detected 2026-11-06, so treat as historical material) lists several changes with mixed dates: Balloon sinus dilation criteria revised effective 08/01/2026; surgical treatments for lipedema/lymphedema revised effective 10/01/2026; Cohere commercial/Medicaid and Medicare Advantage policy revisions and a new omnibus policy effective 09/01/2026; and a Cohere portal change effective 09/01/2026 requiring clinical documentation to be attached at prior authorization submission. Several other items (rendering provider requirement, PointClickCare ADT, Medicare GLP-1 Bridge) are ongoing or undated and should be checked for current applicability.
HealthPartners · Identified Oct 2, 2026High impact
Fast Facts Newsletter - October (Special Edition) 2026
HealthPartners released multiple policy updates effective immediately and 12/15/2026, including coverage changes for DME, rhinoplasty procedure requirements, investigational services (adding virtual reality CBT devices and renal denervation as non-covered, removing tricuspid valve repair from investigational status), and reimbursement policy updates adding CMS HCFA 1450 form requirements. Additionally, five reimbursement policies were updated with clearer guidance. Billing teams must immediately verify rendering provider requirements on all claims and ensure Minnesota Medicaid provider enrollment is active to avoid denials.
HealthPartners · Identified Oct 1, 2026High impact
Fast Facts Newsletter - October (Special Edition) 2026
HealthPartners released a comprehensive policy update affecting coverage, medical policies, reimbursement procedures, and DME/surgical policies. Key changes include: (1) Transcatheter tricuspid valve repair (0569T, 0570T) now covered without prior authorization; (2) Virtual reality CBT devices and renal denervation added as non-covered/investigational services; (3) Rhinoplasty policy simplified with reduced conservative treatment requirement (1 month vs 3 months); (4) DME policy updated for Minnesota Medicaid to exclude bidets and bath equipment in facilities; (5) Five reimbursement policies updated to add CMS HCFA 1450 form guidance; (6) Multiple Cohere coverage policies under revision effective 12/01/2026 affecting cardiac, vascular, spinal, and imaging procedures.
Aetna · Identified Sep 29, 2026High impact
OfficeLink Updates - September 2025 newsletter
This is an Aetna September 2025 newsletter announcing multiple upcoming policy changes including new claim edits effective December 1, 2025, changes to the National Precertification List effective January 1, 2026, and updates to commercial drug lists effective January 1, 2026. The newsletter also highlights biosimilar prescribing guidance, behavioral health updates including ABA medical necessity guide changes, and state-specific regulatory updates across 19 states.
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.
HealthPartners · Identified Jul 1, 2026High impact
Fast Facts Newsletter - July 2026
Cohere Health coverage criteria for Commercial, Medicaid and Medicare Advantage plans are revised, and a new Omnibus Codes (Musculoskeletal Care and Pain Management) policy applies to services that require Cohere prior authorization, effective September 1, 2026. Prior authorization submissions made through the Cohere portal must include clinical documentation at the time of submission, and fax and phone submissions are unchanged. The Medicare GLP-1 Bridge program runs from July 1, 2026 through December 31, 2027, with CMS managing prior authorization, claims adjudication and payment to pharmacies for eligible Part D beneficiaries.
HealthPartners · Identified Jun 19, 2026High impact
Fast Facts Newsletter - May 2025
Effective 07/01/2025, prior authorization is required through Cohere Health for HealthPartners Level Funded Self-Insured Commercial plans for a specific list of cardiovascular and musculoskeletal services, and Cohere Health's coverage criteria will be used for those plans. Also effective 07/01/2025, prior authorization is required under Medicare for Deep Brain Stimulation for Essential Tremor and Parkinson's Disease and for Phrenic Nerve Stimulation, and a new reimbursement policy for add-on code G2211 takes effect.
HealthPartners · Identified Jun 19, 2026High impact
Fast Facts Newsletter - July 2025
Effective 7/1/2025, non-urgent laboratory services performed by non-contracted labs for Medicaid and MinnesotaCare members are not covered, and the balance may not be billed to the member, so these members must be sent to HealthPartners contracted, in-network labs unless prior authorization is granted or the service is urgent or emergent. Formulary updates to be posted by 9/1/25 remove long-acting G-CSF products from the pharmacy benefit, and those medications are available on the medical benefit. The coverage updates add CPT codes 64596 and 64597 to the implanted peripheral nerve stimulation policy and clarify the documentation needed for lumbar spinal fusion when a member cannot complete physical therapy.
HealthPartners · Identified Jun 19, 2026High impact
Fast Facts Newsletter - August (Special Edition) 2025
Effective 10/01/2025, intraosseous radiofrequency ablation of the basivertebral nerve requires prior authorization, and it is covered when the member meets the listed criteria for chronic non-radicular low back pain, Modic changes on MRI and nonsurgical conservative treatment. Emtricitabine/tenofovir (Descovy) no longer requires prior authorization, and member costs are updated to a $0 copay when it is requested for HIV PrEP. Reported as already effective in the historical source, the InterQual May 2025 release applies to the listed skilled nursing facility criteria subsets, and MCG 29th edition criteria are used for applied behavioral analysis for autism spectrum disorders.
HealthPartners · Identified Jun 19, 2026High impact
Fast Facts Newsletter - November 2025
Effective 1/1/2026, prior authorization is required for acute inpatient rehabilitation and long-term acute care hospitalization for Commercial and Minnesota Health Care Programs plans, and for acute inpatient rehabilitation for Medicare Advantage plans. Prior authorization is not required for MRI breast CPT codes 77046 and 77048 or HCPCS codes C8903 and C8905 for Commercial, Medicaid and Medicare Advantage plans, Reported as already effective in the historical source. Humira and Hadlima are being removed from the commercial formulary with adalimumab biosimilars added as replacements, and laboratory PLA codes are listed as not reimbursable effective 1/1/2026.
Minnesota Medicaid (MHCP) · Identified May 22, 2026High impact
Potential scam related to revalidation
The Minnesota Department of Human Services has issued a fraud alert regarding unauthorized phone calls impersonating DHS staff requesting enrollment and private health information under the guise of revalidation. Billing and administrative staff must immediately educate themselves and providers on this scam, verify caller identity through official channels (651-431-2700), and never provide sensitive information over unsolicited calls. Legitimate revalidation requests will be in writing and will not solicit patient/recipient data over the phone.
Minnesota Medicaid (MHCP) · Identified May 5, 2026High impact
Use modifiers with physical therapy (PT) and occupational therapy (OT) authorizations
Minnesota Health Care Programs (MHCP) now requires specific modifiers on all physical therapy (PT) and occupational therapy (OT) authorizations and claims: modifier GO for OT services, modifier GP for PT services (regardless of whether provided by therapist or assistant), and modifier U7 when an assistant provides services without the supervising therapist on site. Authorization requests and corresponding claims must match exactly, including modifiers, or claims will be denied. For members with third-party liability or Medicare, modifiers KX, CO, and CQ must also be used when appropriate.
Blue Cross and Blue Shield of Minnesota · Effective Nov 2, 2026Medium impact
Upcoming Policies effective November 2, 2026
Revised medical policies for lumbar or thoracic spinal fusion (IV-87), sacral nerve neuromodulation (IV-83), bariatric surgery (IV-19) and cryoablation of solid tumors (IV-05) are effective November 2, 2026. The spinal fusion policy sets when fusion may be considered medically necessary for scoliosis, emergent conditions, instability, anticipated instability, recurrent disc herniation, spondylolisthesis, adjacent segment disease and repeat fusion at the same level. The other policies set criteria for temporary and permanent sacral nerve neuromodulation, initial and revision bariatric surgery, and cryoablation for specific solid tumors and bone metastases, and each marks other uses as experimental or investigative.
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.
HealthPartners · Effective Nov 1, 2026Medium impact
Fast Facts Newsletter - September 2026
Effective 11/01/2026, HealthPartners requires prior authorization for reduction mammaplasty under a new policy for fully insured commercial, self-insured level funded commercial and Minnesota Health Care Program plans. Cohere Health coverage criteria for Commercial and Medicaid plans and for Medicare Advantage plans were revised, and new Commercial/Medicaid and Medicare Advantage policies were added, effective 11/01/2026. Substance use disorder services must be billed under the Minnesota Department of Human Services Behavioral Health Fund Billing Grid effective October 1, 2026.

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Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Percutaneous Coronary Intervention - Medicare Advantage (Revised)

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Cardiac Catheterization and Coronary Angiography - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Provider signature requirements for HCBS members support plans

Fast Facts Newsletter - May 2026

Breast Imaging - Medicare Advantage (Revised)

Changes to Substance Use Disorder (SUD) treatment services

CMS Managed Care Plan audit and record requests for EIDBI and peer recovery services providers

Early Intensive Developmental and Behavioral Intervention (EIDBI) claim denials for services billed with CPT code H0046 UB resolved

Update on H0032 and H0046 reimbursement rates for EIDBI services

New DME process for select members in multiple states

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Upcoming Policies effective July 7, 2025

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Hereditary cancer testing policy reminder

Fast Facts Newsletter - July 2026

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Potential scam related to revalidation

Use modifiers with physical therapy (PT) and occupational therapy (OT) authorizations

Upcoming Policies effective November 2, 2026

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Fast Facts Newsletter - September 2026