Nevada 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 Nevada, so your billing and compliance teams can act before the effective date, not after a claim denial.
Anthem Medicare Advantage is implementing a new reimbursement policy effective December 1, 2026, that prohibits pass-through laboratory billing (modifier 90) for professional and outpatient facility providers, requiring them to bill directly instead. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and has been consolidated into this new combined policy.
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claim forms. These services are only reimbursable when submitted by the rendering provider on CMS-1500 professional claim forms using the applicable codes. Participating providers cannot balance bill members for this change.
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claims. These services are now eligible for reimbursement ONLY when submitted by the rendering provider on CMS-1500 (professional claim form). Billing teams must route these services to the correct claim form type to avoid denials.
Effective December 1, 2026, Anthem will no longer reimburse medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 (facility claims). These services are now eligible for reimbursement ONLY when submitted on CMS-1500 (professional claim form) by the rendering provider. Billing teams must immediately audit billing workflows to prevent claim denials and ensure correct claim form submission.
Effective December 1, 2026, Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for laboratory services billed with modifier 90 (pass-through billing). Providers must bill directly for laboratory services and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and is consolidated into this new policy. The prior modifier 91 policy (G-06020) is being retired.
Nevada Medicaid will end-date CDT code D1999 (used for diabetic dental services under the 1115 Whole Mouth Whole Body Dental Demonstration Waiver) effective January 1, 2027. Starting that date, Tribal Health Clinics (PT 47) will bill covered dental services under the T1015 encounter rate, while Federally Qualified Health Centers (PT 17 Specialty 181) will bill using D2999 and applicable shadow billing codes.
Starting January 1, 2027, Nevada Medicaid is implementing new community work requirements for adults ages 19-64, requiring 80 hours of work, school, or volunteering per month to maintain eligibility. Additionally, redetermination cycles are changing from annual to semi-annual for affected members. Billing teams must prepare to verify member eligibility and redetermination dates, as non-compliance with work requirements will affect coverage.
Effective January 1, 2027, Ambetter from SilverSummit Healthplan will discontinue coverage for 45 HCPCS H codes (primarily behavioral health and support services) while adding coverage for H0006. Billing teams must identify all claims using the discontinued codes and implement alternative billing strategies or obtain patient financial responsibility agreements.
Nevada Medicaid is implementing Dental Shadow Billing for FQHCs effective January 1, 2027. FQHCs providing dental services must transition from CPT 41899 (CMS 1500 form) to ADA code D2999 (ADA form/837D transactions), discontinue DBA Supplemental Payment billing after December 31, 2026, and configure systems to use Primary and Supplementary Shadow Billing Codes for dental encounter reporting.
Starting February 1, 2027, Nevada Medicaid will deny claims from home health, personal care services, and waiver providers that do not match verified visit data in electronic visit verification (EVV) systems. Currently these mismatches generate informational error codes only; the practice must ensure all claim details align with EVV system records to avoid future denials.
Effective February 26, 2027, Nevada Medicaid is closing procedure code H0038 (Self-help/peer services) for billing by Provider Types 14 (Behavioral Health Outpatient Treatment) and 26 (Psychologist). Only providers enrolled as PT 97 (Peer Support Specialist) or PT 93/706 (Peer Recovery Support Specialist) may bill H0038 going forward. Peer support specialists can still link to PT 14 and PT 26 groups.
Effective February 1, 2027, Anthem will stop separately reimbursing moderate sedation services (revenue codes 0371 and 0372) on inpatient facility claims when reported with room and board charges for Commercial plans in New York and eight other states. Practices must stop billing these codes separately on inpatient UB-04 claims for Anthem members, as payment is now bundled into room and board reimbursement.
Effective February 1, 2027, Anthem will no longer separately reimburse moderate sedation services (revenue codes 0371 and 0372) on inpatient facility claims when reported with room and board charges; reimbursement is now bundled into room and board payment. Billing teams must stop billing these codes separately on inpatient UB-04 claims for Anthem Commercial members in Georgia and other affected states.
Silver State Scripts Board changed Nevada Medicaid's Preferred Drug List effective November 1, 2026, moving multiple drugs between preferred and non-preferred status, adding prior authorization requirements to some agents, and removing discontinued products. The billing team must track which drugs patients are prescribed, obtain prior authorizations where newly required, and expect claim denials for non-preferred drugs or discontinued products without prior auth or member exception requests.
UnitedHealthcare's individual exchange botulinum toxin policy was revised effective November 1, 2026, which has already passed. The policy now applies in Massachusetts and New York, refers Nevada to the UnitedHealthcare Commercial version, and drops several diagnosis requirements for cervical dystonia, chronic anal fissures and detrusor overactivity, while HCPCS J0589 is now clarified for Daxxify and new eye-related ICD-10 codes were added for J0585 and J0586.
Effective November 1, 2026, Anthem is implementing new reimbursement guidance for laboratory service modifiers 90, 91, and 92. Modifier 90 (pass-through laboratory billing) will no longer be reimbursed—the performing provider must bill directly. Modifiers 91 and 92 guidance remains unchanged but is being consolidated into a single policy. Billing teams must immediately audit claims and update systems to prevent denials for modifier 90 usage.
Effective November 1, 2026, Anthem Blue Cross and Blue Shield is changing how unattended and home sleep studies must be billed. These services must now be billed as professional services on CMS-1500 forms only—they are no longer eligible for reimbursement when billed on UB-04 facility claim forms. Billing teams must ensure sleep study claims are submitted on the correct form type or face denial.
Effective November 1, 2026, Anthem is updating its sleep studies reimbursement policy to clarify that unattended and home sleep studies must be billed as professional services on CMS-1500 forms only. These services are NOT eligible for reimbursement when billed on UB-04 facility claim forms. This policy now applies to both professional and facility care providers in multiple states including New York.
Nevada Medicaid has closed procedure code T1015 (Clinic Visit/Encounter, All-Inclusive) for billing by Provider Type 17 (Special Clinics) specialty 181 (Federally Qualified Health Centers) effective October 26, 2026. This is a go-forward change; no claims will be automatically reprocessed.
Nevada Medicaid has implemented new shadow billing requirements for Provider Type 63 (Psychiatric Residential Treatment Facilities) effective October 19, 2026. Providers must use encounter revenue code 0911 with qualified CPT codes as shadow procedure codes alongside Room & Board codes, though enforcement is deferred until 2027. A supplemental document listing approved shadow billing codes will be posted to the Billing Information webpage.
Effective October 19, 2026, Nevada Medicaid is implementing new shadow billing requirements for Provider Type 63 (Psychiatric Residential Treatment Facilities). Providers must now bill encounter revenue code 0911 with qualified CPT codes as shadow procedure codes in addition to Room & Board codes, though enforcement will not begin until 2027. Only one encounter will be paid per person per day regardless of multiple shadow billed codes submitted.
Nevada Medicaid is enforcing error code 769 to deny telehealth claims where a single provider bills as both the originating site and distant site for the same patient on the same date of service. This policy change became effective October 12, 2026, and claims will not be automatically reprocessed; providers must ensure compliance going forward.
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.
Nevada Medicaid corrects the age threshold for the special rate applicable to private psychiatric residential treatment facilities (PRTF) for complex cases. The special rate now applies only to children under 9 years old; children 9 years and older must meet complex case criteria defined in the updated FA-15 prior authorization form. This is a correction to Web Announcements 3970 and 3999.
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.
Nevada Medicaid has added new CPT, HCPCS, and ADA codes effective October 1, 2026. All claims using Quarter 4 2026 codes will initially suspend with error code 853 until rates and policy details are updated in the MMIS system. Providers can submit retroactive prior authorization requests during this interim period without standard timeliness penalties.
Nevada Medicaid's MMIS has been updated with CMS NCCI Quarter 4 2026 files effective October 1, 2026. The system will now apply updated Medically Unlikely Edits (MUE) and Procedure-to-Procedure (PTP) edits to process claims. Billing teams must ensure correct modifier combinations and code pairings are used to prevent claim denials.
Effective October 1, 2026, Nevada Medicaid is restricting Hospital Presumptive Eligibility (PE) and Pregnancy PE eligibility based on federal immigration law changes (H.R.1 Section 71109). Only specific non-citizen groups—including LPRs meeting the 5-year bar, Cuban/Haitian entrants, COFA migrants, and those qualifying under CHIPRA 214—will remain eligible. Previously eligible groups (refugees, asylees, humanitarian parolees, TPS holders, trafficking victims, VAWA self-petitioners) will lose PE eligibility starting October 1, 2026, unless they qualify under alternative categories.
Nevada Medicaid is implementing new CPT, HCPCS, and ADA codes for Quarter 4 2026, effective October 1, 2026. New codes will initially suspend with error code 853 until rates and policies are loaded into the system. Providers can submit retroactive prior authorization requests during this transition period, with timeliness requirements waived for new codes requiring prior auth.
Starting October 1, 2026, Nevada Medicaid Fee-For-Service will incorporate the 340B ceiling price into its outpatient drug reimbursement methodology. When the 340B ceiling price is the lowest applicable value in the established drug reimbursement logic, it will be used for reimbursement calculations. Covered entities must ensure their 340B Acquisition and Accountability Cost (AAC) is submitted to Nevada Medicaid, and pricing disputes must follow HRSA's 340B Administrative Dispute Resolution process.
Effective October 1, 2026, Nevada Medicaid Fee-for-Service will integrate the 340B ceiling price into its outpatient drug reimbursement methodology. When the 340B ceiling price (calculated from Average Manufacturer Price and Unit Rebate Amount) is the lowest applicable value in the reimbursement logic, it will be used for reimbursement. Covered entities must submit their 340B Actual Acquisition Cost (AAC) to Nevada Medicaid, and pricing disputes must follow HRSA's 340B Administrative Dispute Resolution process.
Effective October 1, 2026, Anthem will deny reimbursement for all claims containing a Provider Preventable Condition (PPC) diagnosis code, specifically HAC01 (retention of a foreign object after surgery), including related services. The policy applies to professional and facility claims across multiple states. Providers are prohibited from balance billing members for denied claims under this policy.
Anthem is implementing a Provider Preventable Conditions (PPC) reimbursement policy effective October 1, 2026, that denies reimbursement for claims containing Never Event diagnosis codes, specifically HAC01 (retention of foreign object after surgery). This policy applies to professional and facility claims in Ohio and nine other states. Providers are prohibited from balance billing members for denied claims under this policy.
Effective October 1, 2026, Anthem will not reimburse professional provider and facility claims that include diagnosis codes for Provider Preventable Conditions (PPCs), specifically Hospital Acquired Conditions (HACs) including HAC01 (retention of foreign object after surgery). Providers are prohibited from balance billing members for non-reimbursed claims. The policy was originally announced with a delayed implementation; Anthem reserves the right to retroactively recoup payments to the originally announced effective date.
Nevada Medicaid is changing the Active Directory domain authentication for CAQH/CORE EDI services from NVPAD to NV. Billing teams must update service account credentials from NVPAD\userid to NV\userid format by September 28, 2026. A scheduled maintenance window will occur September 27–28, 2026, during which the eligibility and claim verification services will be unavailable.
Nevada Medicaid clarifies that members receiving residential substance use treatment at ASAM levels 3.1, 3.5, or 3.7 (PT 93 providers) cannot simultaneously bill outpatient SUD services on the same date of service, except on admission and discharge dates. A specific list of outpatient codes is prohibited from being billed concurrently with residential SUD codes to eliminate duplicative billing.
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.
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.
Nevada Medicaid now allows prior authorization to exceed the 12-hour daily service limit for procedure code T1016 (Case Management, each 15 minutes) for five Home and Community Based Services Waiver programs with specialty 303 (Private Case Management). Claims exceeding 12 hours per day without prior authorization will continue to deny with error code 5738. This is a go-forward change with no retroactive reprocessing.
Nevada Medicaid will now correctly deny claims billed with modifier 26 (Professional Component) or TC (Technical Component) when a corresponding global claim has already been paid for the same recipient and date of service. Effective August 17, 2026, these unbundled claims will be denied with error code 6134. Providers must stop billing component modifiers for global procedures to avoid claim denials.
Nevada Medicaid released guidance on the top 10 claim denial reasons for July 2026 professional claims, with specific resolution instructions for each error code. Billing teams must immediately review claims with error codes 452, 1010, 1047, 1076, 1009, 1048, 1008, 5035, and 1854 and implement corresponding corrective actions to reduce denials.
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.
Nevada Medicaid has introduced a new revenue code 0120 for complex case rates at psychiatric residential treatment facilities (PRTF) for children under 9 or those meeting complex case criteria, effective August 1, 2026. Providers must use Form FA-15 to request this rate and cannot submit revenue codes 0100 and 0120 simultaneously. If the wrong code was initially submitted, providers must file a data correction (Form FA-29) within 5 business days.
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