What insurance policy changes affect Montana providers?

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

How often are Montana 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 Montana insurance policy changes?

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

PAYER POLICY CHANGES

Montana Insurance & Medicaid Policy Updates

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

BCBS Montana · Effective Dec 1, 2026High impact
New Claims Editing Rules To Be Implemented in December 2026
Blue Cross Blue Shield of Montana is implementing new claims editing rules effective December 1, 2026, that will enforce specific dosage and frequency limits for five injectable drugs (Denosumab, Aflibercept, Ranibizumab, Pasireotide, and Ranibizumab-eqrn) and require proper application of drug wastage modifiers. Claims exceeding these limits will be edited with reason codes beginning with 'G' and will be subject to denial or adjustment.
BCBS Montana · Effective Dec 21, 2026High impact
Prior Authorization Changes for Some Government Program Members
Blue Cross and Blue Shield of Montana is removing prior authorization requirements for specific procedure categories (proprietary laboratory analyses, drugs and biologics, molecular pathology/genetics, infectious disease molecular testing, radiology and advanced imaging, orthopedic surgery, foot and ankle surgery, plastic/reconstructive surgery, vascular surgery, organ transplant, general surgery, ophthalmology, and miscellaneous specialty procedures) for Medicare Advantage members effective December 21, 2026. Additionally, the organization will begin phasing out Recommended Clinical Review options starting January 1, 2027, with complete removal expected by end of 2027 for most commercial members.
PacificSource Health Plans · Effective Dec 22, 2026High impact
December 2026 Drug List Change Notification (Commercial)
PacificSource is implementing comprehensive drug list changes effective December 22, 2026, including 24 new formulary additions across commercial and state-based plans (OR, ID, MT, WA), updates to prior authorization criteria for 11 drug classes, and removal of prior authorization requirements for Breztri aerosol. The billing team must update prior authorization workflows, tier assignments, quantity limits, and step therapy requirements in billing systems to reflect these changes.
BCBS Montana · Effective Jan 1, 2027High impact
Prior Authorization Changes for Some Commercial and Government Program Members
Blue Cross Blue Shield of Montana is restructuring prior authorization requirements effective January 1, 2027 (with one change effective October 1, 2026) for commercial, Medicare Advantage, and Medicaid members. Genetic testing, medical oncology therapy, provider-administered drugs, oncology drugs, orthotics, wound care, and DME codes are being added to or transferred between utilization management reviewers (Carelon, BCBSMT, EviCore). Additionally, recommended clinical review will be phased out for most commercial members by end of 2027.
BCBS Montana · Effective Jan 1, 2027High impact
New Digital Interfaces To Simplify Prior Authorization Requests
Starting January 1, 2027, Blue Cross Blue Shield Montana will launch new application programming interfaces (APIs) to streamline prior authorization requests and provide real-time access to patient data, encounter information, and claims data through your electronic health record system. This CMS-required change applies to Medicare Advantage, Medicaid, and select commercial members, and is designed to reduce administrative burden and expedite treatment decisions.
BCBS Montana · Effective Jan 1, 2027High impact
We’ll Begin Removing Recommended Clinical Review as an Optional Medical Necessity Review, Effective Jan. 1, 2027
Blue Cross Blue Shield of Montana will eliminate 'Recommended Clinical Review' as an optional medical necessity review process for commercial members, phasing it out throughout 2027 and completing removal by December 31, 2027. Services that previously used recommended clinical review will transition to requiring prior authorization instead. This change does not affect Medicare or Medicaid members.
BCBS Montana · Effective Jan 1, 2027Medium impact
Changes Coming to the Medical Drug Benefit Program
Effective January 1, 2027, Blue Cross Blue Shield of Montana is expanding its Medical Drug Benefit Program to update coverage for prescription drugs administered by healthcare providers in clinical settings. The program will now define coverage for select medical drugs, including therapeutic alternatives, new-to-market drugs, FDA-accelerated approval indications, and drugs with limited medical benefit coverage. This change applies only to commercial members and requires prior authorization and exception requests for noncovered drugs.
BCBS Montana · Effective Jan 1, 2027Medium impact
Updates to Behavioral Health Substance Abuse Criteria for Utilization Management
Effective January 1, 2027, Blue Cross Blue Shield of Montana will expand its use of ASAM (American Society of Addiction Medicine) Criteria 4.0 for medical necessity reviews to include adolescents, in addition to the existing adult population. Previously, ASAM 4.0 was used only for adults; now it will apply to both adult and adolescent substance abuse and behavioral health services. Billing and prior authorization staff must be aware this criteria change may affect clinical review standards for adolescent behavioral health claims.
BCBS Montana · Effective Jan 1, 2027Medium impact
Watch for New Edge Benefit Plan Members in 2027
Blue Cross and Blue Shield of Montana is introducing new Edge benefit plans powered by Easify starting January 1, 2027. These are copay-only PPO plans with tiered copay options based on provider selection. Billing teams must verify member ID cards, confirm copay amounts via Availity Essentials before service, and ensure rendering provider NPIs are included on all claims.
BCBS Montana · Effective Feb 1, 2027Medium impact
Enhanced Review of Laboratory, Genetic and Molecular Testing Claims
Effective February 1, 2027, Blue Cross and Blue Shield of Montana will implement enhanced claims review for laboratory, genetic, and molecular testing services using AMA and CMS National Correct Coding Initiative guidelines. Claims will be reviewed by Concert, a third-party vendor, to ensure proper coding alignment; denied claims will receive notification with next steps.
PacificSource Health Plans · Effective Oct 22, 2026High impact
October 2026 Drug List Change Notification (Commercial)
Effective October 22, 2026, PacificSource is implementing major formulary changes affecting 40+ medications across commercial and state-based plans (OR, ID, MT, WA). Changes include new drug additions at various tiers with prior authorization and quantity limits, removal of brand-name drugs with generic alternatives, and updates to prior authorization criteria for multiple drug classes. Billing teams must update systems to reflect new tier placements, prior authorization requirements, and quantity limit enforcement.
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.
Humana · Effective Sep 1, 2026High impact
Spinal Fusion Surgery - Medicare Advantage (Revised)
This is a revised Medicare Advantage medical coverage policy for spinal fusion surgery (effective 09/01/2026) that consolidates coverage determination, limitations, coding information, and evidence summaries for cervical, lumbar, and thoracic spinal fusion procedures. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) across geographic jurisdictions and outlines covered procedures including traditional fusion, minimally invasive approaches (DLIF, XLIF, MITLIF), sacroiliac joint fusion, and interlaminar fusion techniques. Billing teams must align claims submission with the applicable MAC LCD based on patient location and ensure procedures meet specific medical necessity criteria outlined in the referenced determinations.
Humana · Effective Sep 1, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for Benign Prostatic Hyperplasia treatments effective September 1, 2026. The policy outlines coverage determinations for multiple BPH treatment modalities including surgical procedures (TURP, prostatectomy, laser therapies), temporary implanted devices, stents, and diagnostic testing. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) that vary by geographic jurisdiction, requiring billing teams to verify applicable coverage rules based on patient location.
Humana · Effective Sep 1, 2026High impact
Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)
Humana Medicare Advantage has revised its Ambulatory Cardiac Monitoring Devices policy effective September 1, 2026. The policy provides updated coverage guidance for various cardiac monitoring technologies (Holter monitors, patch recorders, external loop monitors, implantable loop recorders, and mobile cardiac outpatient telemetry) with MAC-specific coverage determinations by geographic jurisdiction. The policy document appears incomplete but establishes that medical necessity determinations will follow applicable NCDs and LCDs based on the member's jurisdiction.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for neuroablative techniques used to treat chronic pain, effective 08/06/2026. The policy defines coverage criteria, eligible procedures (including radiofrequency ablation, cryoablation, chemical neurolysis, and specialized devices like Intracept), and references MAC-specific LCDs and billing codes by geographic jurisdiction. Billing teams must verify applicable MAC guidelines for their state and ensure claims comply with local coverage determinations.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy on neuroablative techniques for chronic pain management, effective 08/06/2026. The policy defines covered denervation procedures (radiofrequency ablation, cryoablation, facet denervation, basivertebral nerve ablation, and others) and references MAC-specific LCDs and NCDs that vary by geographic jurisdiction. Billing teams must verify applicable MAC requirements for their region before processing claims for these procedures.
Humana · Effective Aug 3, 2026High impact
Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy on genetic testing for hereditary cancer syndromes, effective August 3, 2026. The policy establishes coverage guidelines for germline genetic testing across multiple cancer types (melanoma, gastric cancer, neuroendocrine tumors, renal cell carcinoma, and others) and references specific MAC-based Local Coverage Determinations (LCDs) that vary by geographic jurisdiction. Billing teams must verify applicable MAC jurisdiction and LCD requirements before processing claims.
Humana · Effective Aug 3, 2026High impact
Breast Reconstruction - Medicare Advantage (Revised)
Humana Medicare Advantage has revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
Humana · Effective Aug 3, 2026High impact
Breast Excision and Mastectomy - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its Breast Excision and Mastectomy policy (HUM-1254-009) effective 08/03/2026. This revised policy clarifies coverage criteria for breast lesion excisions (CPT 19120, 19125), partial mastectomies (CPT 19301, 19302), and gynecomastia mastectomy (CPT 19300) across multiple MAC jurisdictions. The policy establishes specific medical necessity criteria based on biopsy results, lesion characteristics, and anatomical considerations, and applies jurisdiction-specific Local Coverage Determinations (LCDs) for Medicare Administrative Contractors.
Humana · Effective Aug 3, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy for Benign Prostatic Hyperplasia (BPH) treatments that became effective on August 3, 2026. The policy outlines coverage for multiple surgical and minimally invasive treatment modalities including TURP, laser therapies, temporary implanted devices, and stents, with specific coverage determinations varying by MAC jurisdiction. Billing teams must verify applicable MAC-specific LCDs and NCDs by geographic location before processing BPH treatment claims.
BCBS Montana · Effective Aug 1, 2026High impact
Review Changes to Anesthesia Rates for Commercial Plans
Blue Cross Blue Shield of Montana is updating anesthesia conversion factors for commercial plans, effective August 1, 2026. Billing teams must access the updated RBRVS and Anesthesia Conversion Factors Policy through Availity® Essentials Plan Document Viewer to obtain the new rates for accurate claim submission.
BCBS Montana · Effective Aug 1, 2026High impact
Prior Authorization Changes for Some Commercial and Government Program Members
Blue Cross and Blue Shield of Montana is updating prior authorization requirements for commercial, Medicare Advantage, and Medicaid members, effective on staggered dates between August and October 2026. Changes include additions and removals of radiology, molecular genetic testing, medical oncology, and miscellaneous codes under different utilization management vendors (Carelon, BCBSMT, EviCore), and implementation of a Part B Step Therapy Program for Medicare Advantage members.
BCBS Montana · Effective Jul 15, 2026High impact
New Claims Editing Rules To Be Implemented in July 2026
Blue Cross Blue Shield of Montana is implementing 18 new automated claims editing rules in their Lyric software database effective July 15, 2026. These rules will automatically deny or rebundle claims that don't meet specific coding requirements, with denials showing reason codes beginning with 'G'.
BCBS Montana · Effective Jul 8, 2026High impact
Two New Claims Editing Rules To Be Implemented in July 2026
Blue Cross Blue Shield of Montana will implement two new claims editing rules in July 2026 that will automatically deny claims with coding errors. The first rule checks for mismatched laterality modifiers (LT/RT/50) with diagnoses, and the second validates HCPCS codes used with implant revenue codes 275, 276, and 278.
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.
BCBS Montana · Effective Jul 1, 2026High impact
Claim Editing Changes for Evaluation and Management Services for Commercial Members, Effective July 1, 2026
Effective July 1, 2026, Blue Cross Blue Shield of Montana will implement enhanced claim editing for evaluation and management (E&M) services on commercial plans. Claims will be automatically reviewed against AMA guidelines, and if the documentation doesn't support the billed E&M level, reimbursement will be reduced to the validated lower level of service.
PacificSource Health Plans · Effective Jun 22, 2026High impact
June 2026 Drug List Change Notification (Commercial)
PacificSource is implementing major formulary and prior authorization changes effective June 22, 2026, including 16 new drug additions across multiple tiers, removal of 5 standalone policies consolidated into broader categories, and state-specific formulary removals for OR/ID/MT/WA members. Billing teams must update systems to reflect new prior authorization requirements, quantity limits, step therapy rules, and limited access restrictions across numerous medications.
BCBS Montana · Effective Jun 1, 2026High impact
Reimbursement Policy Updates
Blue Cross Blue Shield of Montana updated 26 reimbursement policies covering laboratory testing, durable medical equipment, and facility services. These policies describe payment rules and methodologies for CPT, HCPCS, and ICD-10 coding for claims processing.
PacificSource Health Plans · Effective May 22, 2026High impact
May 2026 Drug List Change Notification (Commercial)
PacificSource updated its commercial drug formulary effective May 22, 2026, adding 10 new medications with tier 3 (or tier 4 in OR/ID/MT/WA) designations and various restrictions including prior authorization, quantity limits, and step therapy requirements. The update also retired the Fibrates policy due to drug discontinuation, modified prior authorization criteria for 13 drug classes, and removed 4 drugs from the formulary (Acyclovir solution, Megace ES suspension, Sitavig tablet, Triglide tablet).
PacificSource Health Plans · Effective Apr 9, 2026High impact
April 2026 Drug List Change Notification (Commercial)
PacificSource is implementing significant changes to GLP-1 receptor agonist prior authorization criteria, adding Tofidence as a tier 3 formulary drug with medical necessity requirements, updating quantity limits for Journavx Nurtec, and adding formulary exception criteria for Nurtec tablet across commercial plans and state-based drug lists (OR, ID, MT, WA). All changes are effective April 9, 2026.
Molina Healthcare · Effective Apr 1, 2026High impact
PDF Version
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.
BCBS Montana · Effective Apr 1, 2026High impact
Prior Authorization Changes for Some Commercial and Government Program Members
Blue Cross Blue Shield of Montana is implementing prior authorization changes across multiple plan types with different effective dates. Key changes include adding medical transportation and advanced imaging codes for commercial members, miscellaneous codes for Medicare Advantage, and several code additions/removals for Healthy Montana Kids members.
BCBS Montana · Effective Apr 1, 2026High impact
Prior Authorization Changes for Some Commercial and Government Program Members
Blue Cross Blue Shield of Montana is implementing significant prior authorization changes for commercial and government program members, with different review vendors handling various service categories. Commercial members will see changes starting April 1, 2026 (medical oncology code replacements) and July 1, 2026 (addition of radiation oncology, advanced imaging, molecular genetic lab, and drug codes), while Medicare Advantage members will have new Part B Step Therapy and various code additions effective July 1, 2026.
BCBS Montana · Effective Apr 1, 2026High impact
Coding and Compensation Policy Updates
Blue Cross Blue Shield of Montana has updated seven coding and compensation policies effective April 1-15, 2026, covering preventive services, professional provider and hospital outpatient diagnostics, home health, dental with medical benefits, non-physician services, hospice care, and codes with no other standards. Providers must access the updated policies through Availity Essentials Plan Documents Viewer to understand new payment rules and methodologies.
BCBS Montana · Effective Jan 1, 2026High impact
Update: Prior Authorization Changes for Medicare Advantage Members, Effective Jan. 1, 2026
Effective January 1, 2026, Blue Cross Blue Shield of Montana is transferring prior authorization review responsibilities from EviCore healthcare back to BCBSMT for Medicare Advantage members in four specific care categories. All prior authorization requests for advanced musculoskeletal services, sleep medicine, specialty drugs, and genetic testing must now be submitted directly to BCBSMT instead of EviCore.
BCBS Montana · Effective Jan 1, 2026High impact
Changes to Our Prior Authorization Programs for Medicare Advantage
Effective January 1, 2026, Blue Cross Blue Shield of Montana is taking over prior authorization management from EviCore for Medicare Advantage members in several care categories including Advanced Imaging, Musculoskeletal, Sleep Medicine, Medical Specialty Drugs, and Genetic Testing. The change reduces prior authorization requirements to fewer than 20% of codes and all prior auth requests for these categories must now be submitted to BCBSMT instead of EviCore.
BCBS Montana · Effective Jan 1, 2026High impact
Reimbursement Policy Updates
Blue Cross Blue Shield of Montana updated 22 reimbursement policies affecting laboratory testing, behavioral health services, telehealth, and surgical procedures. These updates include changes to compensation rules for various diagnostic tests, Applied Behavioral Analysis for autism, telehealth services, and assistant surgery procedures with effective dates ranging from January 1 to May 20, 2026.
PacificSource Health Plans · Effective Oct 22, 2025High impact
October 2025 Drug List Change Notification (Commercial)
PacificSource is implementing significant changes to prior authorization criteria and preferred drug list (PDL) formulary effective October 22, 2025. This includes updates to 25+ drug policies (adding new medications, removing coverage for others, and changing clinical criteria), 40+ new formulary additions with specialty pharmacy and quantity limits, and removal of 50+ older medications from coverage. Billing teams must immediately identify which medications their patients use and verify coverage status, prior authorization requirements, and tier placement before claims are submitted.
PacificSource Health Plans · Effective Oct 1, 2025High impact
Montana State Based Drug List Change Notification (Commercial)
PacificSource Montana Commercial plans are removing prior authorization requirements and formulary coverage for 60+ medications effective October 1, 2025, spanning hormone therapies, respiratory, diabetes, and specialty drugs. Billing teams must immediately update systems to stop requiring prior authorizations for these medications and verify patient coverage status, as claims submitted with unnecessary prior auth requests may be denied or delayed.
BCBS Montana · Identified Sep 23, 2026High impact
Reimbursement Policy Updates
Blue Cross Blue Shield of Montana has issued a comprehensive reimbursement policy update affecting 16 distinct policies effective between September 1–December 11, 2026. Key changes include updates to Assistant at Surgery reimbursement, Infusion Therapy coding (with archival of old code list on December 10), Telehealth services, Place of Service rules, and coding/compensation methodologies. Billing teams must review each affected policy in Availity Essentials and implement changes by their respective effective dates to avoid claim denials.
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.
BCBS Montana · Identified Sep 1, 2026High impact
Prior Authorization Changes for Some Commercial and Government Program Members
Blue Cross and Blue Shield of Montana is reorganizing prior authorization requirements across commercial and government program members, effective on two dates: October 1, 2026, and January 1, 2027. Changes include removal of behavioral health and miscellaneous codes from certain review processes, addition of radiation oncology and emerging technology codes, and reassignment of oncology, immunology/specialty infusion, and laboratory/molecular diagnostic codes to different utilization management vendors. Billing teams must update their prior authorization submission workflows and tracking systems to reflect these changes.
BCBS Montana · Identified Aug 26, 2026High impact
Reimbursement Policy Updates
Blue Cross Blue Shield of Montana has updated multiple reimbursement policies (formerly coding and compensation policies) effective on various dates between July and December 2026. The updates affect reimbursement rules, methodologies, and coverage determinations for CPT, HCPCS, and ICD-10-CM codes across clinical laboratory testing, chiropractic care, anesthesia, robotic surgery, trauma services, and specialized diagnostic panels. Billing teams must review each specific policy in Availity Essentials and adjust claim submission procedures accordingly.
Medicare/CMS - LCD · Effective Nov 5, 2026Medium impact
Prostate Cancer Detection with IsoPSA®
CGS Administrators' LCD L39284 (Prostate Cancer Detection with IsoPSA®), revised in R4 dated 11/05/2026, provides limited coverage for the IsoPSA® blood test for men 50 and older with a confirmed PSA above 4 and up to 25 ng/mL and no relative contraindication to biopsy such as less than a 10-year life expectancy. The source states its annual review made no changes, and the stated effective date of 11/5/2026 is already before the analysis date of 2026-11-06, so these criteria are already in effect and should be checked for current applicability. The practice should align IsoPSA® orders and claims with these indications and the confirmed-PSA requirement.
UnitedHealthcare · Effective Nov 2, 2026Medium impact
Credentialing transitioning to CertifyOS for some states
UnitedHealthcare is transitioning credentialing activities from Onboard Pro to CertifyOS for providers in Alabama, Montana, North Dakota, South Dakota, and Wyoming, effective November 2, 2026. New credentialing submissions will continue through Onboard Pro with primary source verification completed by CertifyOS, and recredentialing for April 2027 will be managed by CertifyOS starting immediately. On November 16, 2026, providers in these states must use the CertifyOS portal for credentialing applications.
BCBS Montana · Effective Nov 2, 2026Medium impact
New Reconsideration Filing Limit for Commercial NICU Claims with Ineligible Reason Code of CR1, Effective Nov. 2, 2026
Blue Cross Blue Shield of Montana is implementing a new 180-day filing deadline for reconsideration requests on commercial NICU claims with CR1 reason codes (level of care authorization mismatches). Billing teams must submit postservice medical necessity reviews within 180 days of claim finalization and include specific supporting documentation (itemized bill, admission/discharge summaries, and daily progress notes) or lose appeal rights.
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.
BCBS Montana · Effective Oct 13, 2026Medium impact
DPHHS Announces Changes to Gender Dysphoria Coverage for HMK Members in Accordance With New Federal Final Rules, Effective Oct. 13, 2026
Effective October 13, 2026, Montana's Healthy Montana Kids (HMK) and CHIP programs will no longer cover puberty-blocking medications or surgical procedures prescribed, furnished, or performed for gender transition in members under age 19 (under age 18 for Medicaid). Billing teams must deny and not process claims for these services on or after this date.

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New Claims Editing Rules To Be Implemented in December 2026

Prior Authorization Changes for Some Government Program Members

December 2026 Drug List Change Notification (Commercial)

Prior Authorization Changes for Some Commercial and Government Program Members

New Digital Interfaces To Simplify Prior Authorization Requests

We’ll Begin Removing Recommended Clinical Review as an Optional Medical Necessity Review, Effective Jan. 1, 2027

Changes Coming to the Medical Drug Benefit Program

Updates to Behavioral Health Substance Abuse Criteria for Utilization Management

Watch for New Edge Benefit Plan Members in 2027

Enhanced Review of Laboratory, Genetic and Molecular Testing Claims

October 2026 Drug List Change Notification (Commercial)

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

Bariatric Surgery - Medicare Advantage (Revised)

Spinal Fusion Surgery - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)

Breast Reconstruction - Medicare Advantage (Revised)

Breast Excision and Mastectomy - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Review Changes to Anesthesia Rates for Commercial Plans

Prior Authorization Changes for Some Commercial and Government Program Members

New Claims Editing Rules To Be Implemented in July 2026

Two New Claims Editing Rules To Be Implemented in July 2026

Breast Imaging - Medicare Advantage (Revised)

Claim Editing Changes for Evaluation and Management Services for Commercial Members, Effective July 1, 2026

June 2026 Drug List Change Notification (Commercial)

Reimbursement Policy Updates

May 2026 Drug List Change Notification (Commercial)

April 2026 Drug List Change Notification (Commercial)

PDF Version

Prior Authorization Changes for Some Commercial and Government Program Members

Prior Authorization Changes for Some Commercial and Government Program Members

Coding and Compensation Policy Updates

Update: Prior Authorization Changes for Medicare Advantage Members, Effective Jan. 1, 2026

Changes to Our Prior Authorization Programs for Medicare Advantage

Reimbursement Policy Updates

October 2025 Drug List Change Notification (Commercial)

Montana State Based Drug List Change Notification (Commercial)

Reimbursement Policy Updates

Hereditary cancer testing policy reminder

Prior Authorization Changes for Some Commercial and Government Program Members

Reimbursement Policy Updates

Prostate Cancer Detection with IsoPSA®

Credentialing transitioning to CertifyOS for some states

New Reconsideration Filing Limit for Commercial NICU Claims with Ineligible Reason Code of CR1, Effective Nov. 2, 2026

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

DPHHS Announces Changes to Gender Dysphoria Coverage for HMK Members in Accordance With New Federal Final Rules, Effective Oct. 13, 2026