Mississippi 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 Mississippi, so your billing and compliance teams can act before the effective date, not after a claim denial.
Effective December 31, 2026, Mississippi Medicaid will retire CPT code 92507 (speech therapy treatment). Beginning January 1, 2027, CMS will replace it with five new, more specific procedure codes. The billing team must monitor for final code details and updated prior authorization workflows from Medicaid, Telligen, and MCOs, and be prepared to transition claims to the new codes in January 2027.
Effective January 1, 2027, 15 specific diabetes supply HCPCS codes will transition from medical/DME billing to exclusive pharmacy billing on Mississippi Medicaid. A transition period runs October 1–December 31, 2026, during which the billing team must update systems to route these codes to pharmacy claims and ensure providers switch members to preferred products on the Diabetic Supply List (DSL). Eight HCPCS codes for insulin pump supplies and adjunctive CGM remain eligible for medical/DME billing and are unaffected.
Mississippi Division of Medicaid will move fifteen diabetes supply HCPCS codes from the medical/DME benefit to exclusive pharmacy billing effective January 1, 2027, so these supplies will need NDC-based pharmacy claims. A transition period runs from October 1 through December 31, 2026, and the change is aimed at letting Medicaid collect manufacturer rebates. Eight other diabetes supply codes remain eligible for medical/DME billing.
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.
Effective January 1, 2027, Mississippi Medicaid is transitioning all pharmacy prior authorization submissions to mandatory electronic submission through the MESA Provider Portal, replacing paper and phone submission methods. Providers must register for portal access and train staff immediately to avoid claim denials starting in the new year.
Effective 01/01/2027, Ambetter from Magnolia Health will discontinue coverage for 45 HCPCS H codes (behavioral health and substance abuse treatment services) while adding coverage for H0006. Billing teams must immediately identify affected services, update claim submission logic, and prepare providers for coverage gaps to avoid claim denials.
Remicade, infliximab, Neulasta, Neulasta Onpro, Kanjinti, and Selarsdi will no longer be covered effective 01/01/2027, and services related to delivery or administration of a not covered or non-formulary medication are considered not medically necessary. Prolia, Soliris, and Xgeva were set to no longer be covered effective 08/15/2026, and a policy update dated 11/01/2026 added Avsola, Fulphila, Fylnetra, Granix, Ogivri, Ontruzant, Renflexis, Riabni, Starjemza, and Vegzelma as covered products.
Magnolia Health Plan has updated pharmacy and biopharmacy policies effective December 1, 2026, to ensure medical necessity review criteria align with current clinical standards. The specific policy changes are detailed in the HIM Criteria Summary Table PDF, which must be reviewed to identify which medications, biologics, or coverage rules have changed. Billing teams must obtain and review this PDF to determine operational impacts.
Effective January 1, 2027, the BCBSMS policy for interleukin-5 antagonist monoclonal antibodies adds Cinqair (reslizumab) and Exdensur (depemokimab-ulaa) as not covered on any BCBSMS Formulary. It adds Fasenra (benralizumab) as medically necessary when the listed criteria are met, revises the medically necessary criteria, and changes the length of approval from 6 to 12 months. The code tables add HCPCS J0517 as medically necessary and HCPCS J2361 and J2786 as not medically necessary.
Effective 11/01/2026, Selarsdi, Starjemza, Steqeyma, and Yesintek are the ustekinumab formulary options. Avsola and Renflexis were added as medical covered agents for rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, and Cimzia was added as a medical covered agent for polyarticular juvenile idiopathic arthritis. Bimzelx was added as a non-covered medication, and the medical necessity criteria were updated for non-radiographic axial spondyloarthritis, ankylosing spondylitis, active enthesitis-related arthritis, systemic juvenile idiopathic arthritis, Cosentyx 300mg, and Simponi/Simponi ARIA.
Selarsdi, Starjemza, Steqeyma and Yesintek are the ustekinumab formulary options effective 11/01/2026. Stelara, Imuldosa, Otulfi, Pyzchiva and Wezlana are not covered on the State Health Plan Medical Drug Formulary, and Stelara will no longer be covered effective 8/1/25. Avsola and Renflexis changed from non-covered to covered medications for Crohn's disease and ulcerative colitis, with that change dated 11/01/2026.
Effective 11/01/2026, Selarsdi, Starjemza, Steqeyma and Yesintek are the ustekinumab formulary options, and Avsola and Renflexis moved from non-covered to covered medications. Starjemza was added as a Step 1a pharmacy preferred agent and as a medical covered agent for Crohn's disease and ulcerative colitis. Prior authorization is required, and Abrilada, Amjevita, Cyltezo, Hulio, Humira, Hyrimoz, Idacio, Imuldosa, Omvoh, Otulfi, Pyzchiva, Stelara, Velsipity, Wezlana, Yuflyma, Yusimry and Zymfentra are not covered on any BCBSMS formulary. A notice dated 11/01/2026 gives a revised Biosimilar Medications policy effective date of 01/01/2027.
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.
Magnolia Health Plan has updated 15 pharmacy and biopharmacy policies effective October 1, 2026, affecting coverage criteria, dosing requirements, and prior authorization rules for specialty drugs including biologics, oncology treatments, and GLP-1 receptor agonists. Key changes include expanded indications for hemophilia and autoimmune treatments, updated redirection requirements for weight loss and diabetes medications, and FDA approval alignments. Billing teams must update prior authorization workflows and formulary references before the effective date.
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.
Evolent Specialty Services requires prior authorization for 23 cardiology codes covering angioplasty, stent placement and atherectomy in the iliac, femoral and popliteal, tibial and peroneal, and inframalleolar arteries, plus code 92930 for placement of intracoronary stents. The requirement takes effect October 1, 2026 for members of the Ambetter from Magnolia Health Marketplace and Wellcare Medicare health plans.
Effective 10/01/2026, the Code Reference section adds the new ICD-10 diagnosis codes I42.00, I42.01, I42.09, I42.81 and I42.89 for cardiomyopathy. Diagnosis codes I42.0 and I42.8 are marked as deleted 09/30/2026. A human heart transplant is considered medically necessary for selected adult and pediatric patients with end-stage heart failure who meet the listed criteria for patient selection and priority allocation.
Magnolia Health Plan updated 13 pharmacy and biopharmacy policies effective September 1, 2026, reflecting new FDA approvals, formulation changes, age criteria updates, and indication expansions for oncology drugs, immunotherapies, and other specialty medications. Billing teams must verify coverage criteria changes for affected drugs and update prior authorization requirements accordingly.
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.
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 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.
Magnolia Health Plan has updated pharmacy and biopharmacy policies effective September 1, 2026, with changes to medical necessity review criteria. The specific policy details are contained in a PDF document (HIM Criteria Summary Table) that must be reviewed to identify which drugs, biologics, or services are affected by new or modified coverage rules.
Effective September 1, 2026, Devoted Health is transitioning DME, Home Health, and Home Infusion prior authorization and order management to Integrated Home Care Services (IHCS) in Alabama, Mississippi, and Pennsylvania. All orders and prior authorization requests must now be submitted to IHCS through electronic platforms (WellSky CarePort, Availity Essentials, Parachute Health) or by fax to IHCS instead of directly to Devoted Health.
Mississippi Medicaid has clarified and reinforced ownership and managing employee disclosure requirements for provider enrollment, recredentialing, and revalidation. Providers must report all individuals and entities meeting ownership criteria (5% or more direct/indirect/combined interests, secured interests, or corporate roles) and managing employees within 35 days of any changes. Nursing facilities face expanded disclosure requirements including governing body members, officers, and additional disclosable parties.
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.
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.
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 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 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.
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.
This is a Mississippi Medicaid administrative code document (Title 23, Part 200) that establishes general provider information requirements, including a new Electronic Visit Verification (EVV) rule (Rule 1.14). The document covers provider enrollment, claims and billing procedures, beneficiary information, and administrative requirements for Medicaid providers in Mississippi.
Beginning August 1, 2026, Synapse Health will manage all DME ordering and fulfillment for UnitedHealthcare Medicare Advantage and C-SNP members in Florida and Mississippi. DME prescribers must use the Synapse Health e-prescribing portal instead of current ordering methods, and DME suppliers must join the Synapse Health network to continue providing services.
Mississippi Medicaid is updating inpatient hospital payment methodology effective July 1, 2026, including adoption of APR-DRG Grouper Version 43, updated base payment rates ($5,400 to $5,608), adjusted neonate policy multiplier (1.60 to 1.44), and increased cost outlier threshold ($66,000 to $88,000). Hospitals using Solventum software must update their internal systems to reflect these changes for discharges on or after July 1, 2026.
Telligen now requires that prior authorization (PA) requests for therapy services include the appropriate therapy modifier (GN for speech-language, GO for occupational therapy, GP for physical therapy), and these modifiers must match exactly on the corresponding claim to prevent duplicate service denials. The treating provider must be the therapy provider, while the ordering provider must be a physician, PA, or NP.
Mississippi Medicaid is recouping payments for VFC-covered vaccine codes that were billed with non-zero amounts. Effective immediately, all VFC Program vaccine codes for patients ages 18 and under must be submitted with $0.00 billed amount; providers can only bill for vaccine administration services. Adjustments will appear on Remittance Advice dated April 13, 2026.
Molina Care Connections expands telehealth and in-person nurse practitioner services across 22 states with open scheduling for preventive care and chronic condition management. Developmental screening requirements for children ages 1-3 now mandate use of standardized global screening tools (CPT 96110) with specific documentation; domain-specific tools (M-CHAT, ASQ:SE) are no longer billable for this measure. Utilization management criteria and processes remain unchanged but are clarified for provider reference.
Magnolia Health Plan incorrectly paid claims for members not enrolled on the date of service. These claims will be reprocessed on 2/9/2026 as fee-for-service (FFS) claims through Mississippi Medicaid. Your practice will receive both a denied claim (error 512 – Timely Filing) and a reprocessed claim with an ICN beginning with '80' that bypasses timely filing edits. Expect corresponding adjustments or voids from Magnolia and FFS payments from the state.
Effective February 1, 2026, Mississippi Medicaid will suspend claims for any provider who fails to submit their Revalidation or Recredentialing application by the 60-day deadline specified in the notice. Suspended claims will receive specific rejection codes (2080-2089) and will only be released once the application is submitted. Billing teams must monitor revalidation/recredentialing due dates and ensure timely submission to avoid claims processing disruption.
Mississippi Medicaid is implementing emergency billing procedures for pharmacy claims during the declared State of Emergency (Jan 23-27, 2026) due to severe winter weather. Pharmacies may override the 2 Brand/6 Prescription limit and early refill edits by submitting POS claims with NCPDP Field 420-DK = '13 – Payer Recognized Emergency.' Post-event audits will verify appropriate use, and claims lacking supporting documentation may be subject to recoupment.
Effective January 1, 2026, the State and School Employees' Health Insurance Plan (Mississippi) now classifies Spravato (esketamine) as not medically necessary for treatment-resistant depression and major depressive disorder, citing available alternative treatments. All administration and delivery services related to Spravato are also deemed not medically necessary. The drug is considered investigational for all other conditions.
Mississippi Medicaid is transitioning nursing home payment methodology from RUG-IV to Patient-Driven Payment Model (PDPM) effective January 1, 2026. The new model uses a blended approach with five components: Nursing (50%), Physical Therapy (15%), Occupational Therapy (15%), Non-Therapy Ancillary (12%), and Speech Language Pathology (8%).
Mississippi Medicaid has updated reimbursement rates for Home and Community-Based Services (HCBS) across multiple waiver programs, effective January 1, 2026. This affects rates for services including assisted living, day services, job development, respite care, personal care, and various support services under AL, 1915(i) CSP, E&D, IL, ID/DD, and TBI/SCI waiver programs.
Mississippi Medicaid now requires Electronic Visit Verification (EVV) for all personal care and home health services, mandating electronic tracking of service type, provider, recipient, location, date, and start/end times. Providers must use either the state's HHAeXchange portal or an approved contracted EVV solution, with claims submission now required through the EVV system.
Mississippi Medicaid now allows facilities to affiliate individual providers to their organizational provider enrollment, which impacts prior authorization processing. Billing teams must ensure valid rendering provider information is included on CMS-1500 claims to avoid EOB Error Code 1085 denials. Claims from facilities or group providers without proper rendering provider fields will be rejected.
Effective October 1, 2025, Mississippi Medicaid requires the new MS Medicaid Crossover Cover Sheet and Explanation of Medicare Benefits (EOMB) for all paper crossover claims. Paper claims submitted without this form or completed incorrectly will be returned unprocessed, affecting claim processing speed and accuracy.
Effective October 1, 2025, Xifaxan and Trulance will no longer be covered by Mississippi Medicaid because Bausch Health Companies is withdrawing from the federal Medicaid Drug Rebate Program. Bausch Health has established a patient assistance program for affected Medicaid members.
Mississippi Medicaid will reprocess claims that were submitted without a rendering provider ID or with an invalid rendering provider ID. The state will use a hierarchical matching process (NPI match, then taxonomy match, then geography match) to identify the correct rendering provider. Providers whose claims were affected should resubmit corrected claims; if denied for timely filing, they may request an Administrative Review within 90 days.
TrueCare will become a new Coordinated Care Organization (CCO) for Mississippi Medicaid effective July 1, 2025, replacing UnitedHealthcare. Providers must enroll and contract with TrueCare based on their credentialing agency (DOM or other). The policy outlines enrollment procedures specific to each credentialing scenario.
Effective July 1, 2025, United Healthcare will no longer serve as an MCO for Mississippi Medicaid beneficiaries. All UHC-enrolled DOM members will be disenrolled and transferred to new MCOs or Fee-for-Service. The billing team must route all prior authorization requests for services on or after 7/1/2025 to the beneficiary's new assigned MCO, not UHC. Additionally, any pending pre-service appeals must be submitted to UHC by strict deadlines (6/17/2025 for standard, 6/27/2025 for expedited) or they will be directed to the new MCO after disenrollment.
Mississippi Medicaid identified and fixed a configuration issue affecting prior authorizations for incontinence garments (diapers, pull-ups, and blue pads) that caused premature exhaustion of authorized amounts from July 1–September 5, 2025. The Division of Medicaid is reprocessing all impacted claims with dates of service during this period.
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