What insurance policy changes affect Ohio providers?

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

How often are Ohio 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 Ohio insurance policy changes?

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

PAYER POLICY CHANGES

Ohio Insurance & Medicaid Policy Updates

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

Anthem BCBS · Effective Nov 15, 2026High impact
[Ohio] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines
Effective for dates of service on and after Nov. 15, 2026, Carelon's clinical appropriateness guidelines change for Anthem Blue Cross and Blue Shield Medicaid and MyCare Ohio plans in Ohio. Genetic testing guidelines add a requirement that all components of a test must demonstrate clinical utility, and whole exome, whole genome and whole transcriptome analysis are considered not medically necessary. For joint surgery, the required conservative management duration is standardized to 12 weeks across procedures, and new criteria cover electrical and ultrasound bone growth stimulation devices for conditions of the appendicular skeleton.
Anthem BCBS · Effective Nov 15, 2026High impact
[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Effective for dates of service on and after November 15, 2026, the Carelon Medical Benefits Management Clinical Appropriateness Guidelines are updated for Anthem Blue Cross and Blue Shield commercial plans in Ohio. The updates cover vascular embolization, varicose vein treatment, PFO closure, genetic and liquid biopsy testing, joint surgery, hypoglossal nerve stimulators and upper GI endoscopy. For upper endoscopy, EGD for new-onset dyspepsia is medically necessary in patients 55 or older rather than 50 or older, and EGD for weight loss requires a loss of 5% or more of usual body weight over the past 12 months. For joint surgery, conservative management is standardized to 12 weeks across procedures, with a shorter allowance for severe ADL impacts, and shoulder, hip and knee arthroscopy adds an exclusion for Kellgren-Lawrence grade 4 osteoarthritis.
Ohio Medicaid · Effective Nov 16, 2026High impact
5160-1-17.51 - Suspension of medicaid provider claims payments during a pending audit or investigation. (New/Original File)
Ohio Department of Medicaid has established a new rule (5160-1-17.51) effective 2026-11-16 that authorizes suspension of Medicaid provider claims payments during pending audits or investigations. This replaces an emergency rule that expired 2026-10-01. Billing teams must understand that claims may be held without payment during audit/investigation periods.
Anthem BCBS · Effective Nov 28, 2026High impact
[Ohio] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross and Blue Shield has updated 24 medical policies and clinical utilization management guidelines effective November 28, 2026, affecting Medicare Advantage and MyCare Ohio members in Ohio. Changes include revised coverage criteria for wound healing products, cardiac devices, diabetes management systems, laboratory testing, and surgical procedures. Some previously covered services may now be deemed not medically necessary under the new guidelines.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Include anatomical modifiers on outpatient facility claims
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in Ohio will require anatomical modifiers (such as LT/RT for laterality, E1–E4 for eyelids, FA/F1–F9 for fingers, TA/T1–T9 for toes, and coronary artery modifiers) on outpatient facility claims when CPT or HCPCS codes specify anatomical site identification. Claims missing required modifiers or with mismatched anatomical modifiers will not be eligible for reimbursement.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Review Excludes1 coding before submitting claims
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) will apply ICD-10-CM Excludes1 Notes editing to inpatient and outpatient claims for medical and behavioral health services on Medicare Advantage plans. Billing teams must review diagnosis coding for conflicting code combinations before claim submission; claims with unresolved Excludes1 conflicts will be denied and require correction and resubmission.
CareSource · Effective Dec 1, 2026High impact
[Ohio] Avalon Policy Updates
CareSource Ohio Medicaid has partnered with Avalon Healthcare Solutions for laboratory benefits management and is revising 36 laboratory reimbursement policies effective December 1, 2026. These revised policies govern routine lab testing through Avalon's post-service pre-payment clinical claim editing program (RTM). No prior authorization requirement changes are indicated, but billing teams must ensure compliance with updated lab policies on Avalon's website to avoid claim denials.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem Medicare Advantage is implementing a new reimbursement policy effective December 1, 2026, that prohibits pass-through laboratory billing (modifier 90) for professional and outpatient facility providers, requiring them to bill directly instead. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and has been consolidated into this new combined policy.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claim forms. These services are only reimbursable when submitted by the rendering provider on CMS-1500 professional claim forms using the applicable codes. Participating providers cannot balance bill members for this change.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Effective December 1, 2026, Anthem Ohio Medicaid is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for professional and outpatient facility claims billed with modifier 90 (pass-through laboratory billing). Providers performing tests must bill directly and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 policy remains unchanged and continues to allow reimbursement for repeat clinical diagnostic laboratory tests at 100%.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claims. These services are now eligible for reimbursement ONLY when submitted by the rendering provider on CMS-1500 (professional claim form). Billing teams must route these services to the correct claim form type to avoid denials.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield (Ohio) is implementing new prior authorization requirements and quantity limits for five specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for eleven additional specialty medications. Billing teams must begin requesting prior authorization for these drugs on or after the effective date, and include NDC codes on claims to expedite processing.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage in Ohio is implementing a new reimbursement policy that prohibits pass-through laboratory billing using modifier 90—the performing provider must bill directly for reimbursement at 100% of the applicable fee schedule. Modifier 91 guidance remains unchanged and eligible for reimbursement on repeat clinical diagnostic laboratory tests. The existing modifier 91 policy (G-06020) will be retired and consolidated into the new combined policy (G-20001).
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 (facility claims). These services are now eligible for reimbursement ONLY when submitted on CMS-1500 (professional claim form) by the rendering provider. Billing teams must immediately audit billing workflows to prevent claim denials and ensure correct claim form submission.
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Effective December 1, 2026, Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for laboratory services billed with modifier 90 (pass-through billing). Providers must bill directly for laboratory services and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and is consolidated into this new policy. The prior modifier 91 policy (G-06020) is being retired.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (September 2026 Newsletter)
Carelon Medical Benefits Management (Ohio) is updating prior authorization requirements across three service categories: Additional Outpatient, Cardiovascular, and unspecified other services, effective December 1, 2026. The specific requirement changes are not detailed in this bulletin summary, but the full policy documents are referenced and must be reviewed to determine which procedures now require precertification.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Clinical Criteria updates
Anthem Blue Cross and Blue Shield has revised 23 clinical criteria policies and added 4 new ones for medical drug benefits under Medicare Advantage/MyCare Ohio plans, effective December 1, 2026. These updates affect prior authorization and medical necessity requirements for specialty medications across oncology, immunology, ophthalmology, and rare disease categories. Billing teams must obtain updated clinical criteria documentation to ensure accurate prior authorization submissions and claim processing.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Use modifier 25 when billing eligible E&M services with XXX procedures
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Medicaid in Ohio now requires modifier 25 when billing E&M services performed with XXX procedures (those with global surgery indicators, such as injections and infusions). Claims must include documentation proving the E&M service is significant and separately identifiable from the procedure work. Claims lacking supporting documentation may be denied or adjusted.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] 2027 Medicare formulary changes: Prepare now for
Effective January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Ohio will move 10 select medications to nonformulary status, including common drugs for asthma, COPD, diabetes, anticoagulation, and inflammatory conditions. The practice must review patient medication lists, coordinate therapy transitions to covered alternatives before the effective date, and submit pharmacy prior authorizations electronically to avoid claim denials and treatment delays in January.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] National accounts: 2027 standard prior authorization requirements
Anthem Blue Cross and Blue Shield is updating prior authorization (PA) requirements for Ohio-based commercial accounts, effective January 1, 2027. The policy establishes comprehensive PA requirements across inpatient admissions, advanced diagnostic testing, DME/prosthetics, transplants, gene therapies, CAR T-cell treatments, mental health services, and numerous surgical procedures. Billing teams must implement these PA requirements in their workflows and systems before the effective date.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Specialty pharmacy precertification list expands
Anthem Blue Cross and Blue Shield (Ohio) is expanding its specialty pharmacy precertification requirements for Medicare Advantage members. Effective February 1, 2027, three new Part B drugs (golimumab, bevacizumab, and isatuximab) will require prior authorization. Additionally, effective January 1, 2027, step therapy requirements are being added to eight existing Part B medications (denosumab, bendamustine, pemetrexed, and hyaluronate formulations). Noncompliance with precertification requirements may result in claim denial.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] October 2026 Provider Newsletter
This October 2026 Ohio provider newsletter contains multiple policy updates effective January 1, 2027, and November 1, 2026, affecting claims submission, prior authorization requirements, E/M documentation, maternity coding, and medical records handling across Commercial, Medicare Advantage, and Medicaid plans. Key changes include mandatory electronic claims submission (to avoid paper handling fees), expanded inpatient DRG submissions with full medical records, new E/M service requirements, maternity services coding changes, and prior authorization process modifications.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Prior authorization requirement changes (October 2026 Newsletter)
Anthem Blue Cross and Blue Shield has announced changes to prior authorization requirements for Medicare Advantage and Ohio Medicaid Managed Care plans, effective January 1, 2027. The specific details of which services or procedures are affected are not provided in this bulletin excerpt—billing teams must access the full policy documents via the provided links to identify impacted codes and workflows.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Reimbursement policy update: Maternity Services coding changes (October 2026 Newsletter)
Anthem Blue Cross and Blue Shield has issued a maternity services coding changes policy update effective January 1, 2027. The policy document references material amendments to contract and/or changes to prior authorization requirements, but the specific coding changes are not detailed in the provided excerpt. Your billing team must access the full policy document to identify which maternity CPT codes are affected and whether new prior authorization requirements apply.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Medical Policies and clinical guidelines updates
Anthem Blue Cross and Blue Shield (Ohio) has updated 12 medical policies and clinical guidelines effective January 1, 2027, including new coverage criteria for gene therapies, cellular immunotherapy, hearing loss treatment, and various diagnostic/surgical procedures. All updated policies require prior authorization. Key changes include reclassification of several procedures from investigational to non-medically necessary status, and transition of multiple policies from Medical Policy to Clinical UM Guideline format.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Post-acute care authorization process changes
Effective January 1, 2027, Anthem Blue Cross and Blue Shield (MyCare Ohio) is transferring prior authorization and concurrent review for post-acute care services (home health, DME, SNF, IRF, LTACH) from Anthem to Carelon Medical Benefits Management. Providers must submit all new authorization requests through the Carelon provider portal or fax starting January 1, 2027, while continued-stay reviews for patients admitted before that date remain with Anthem.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] National accounts: 2027 standard prior authorization requirements
Anthem Blue Cross and Blue Shield Ohio is implementing updated prior authorization requirements for national accounts effective January 1, 2027. This comprehensive policy change expands PA requirements across inpatient admissions, advanced diagnostic testing, specialized DME/prosthetics, gene therapies, CAR T-cell treatments, mental health services, and numerous surgical procedures. Billing teams must identify all affected services and update authorization workflows to avoid claim denials.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Check Present on Admission indicators to support accurate claim processing
Beginning January 1, 2027, Anthem Blue Cross and Blue Shield Medicaid in Ohio will implement prepayment claim edits to validate Present on Admission (POA) indicators on inpatient facility claims. Claims with missing, inconsistent, or invalid POA information will not be eligible for reimbursement. Billing teams must audit POA reporting on all applicable diagnoses before claim submission to ensure accurate indicator assignment.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Enhancing claims accuracy: expansion of inpatient high-impact DRG submissions with full medical records (October 2026 Newsletter)
Anthem Blue Cross and Blue Shield is expanding requirements for inpatient high-impact DRG submissions to include full medical records, effective January 1, 2027. This change applies to both Commercial and Medicare Advantage plans in Ohio and may affect claims accuracy and submission processes for inpatient admissions.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (October 2026 Newsletter)
Carelon Medical Benefits Management (Anthem Blue Cross and Blue Shield in Ohio) has issued updated prior authorization/precertification requirements for surgical procedures. Multiple effective dates are outlined: January 1, 2027 for Base Surgical (both Commercial and Medicare Advantage) and February 1, 2027 for Surgical SOCs (Commercial). The specific authorization requirement changes are not detailed in this summary document and require review of the full policy links provided.
UnitedHealthcare · Effective Jan 1, 2027High impact
New oncology prior authorization code updates
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
UnitedHealthcare · Effective Jan 1, 2027High impact
Ohio Medicaid: Include ORP NPI to avoid denials
Starting January 1, 2027, Ohio Medicaid claims for designated items and services must include the National Provider Identifier (NPI) of the ordering, referring, or prescribing provider. Claims missing this ORP (Ordering, Referring, and Prescribing) NPI will be denied. Ohio has established a statewide implementation plan with a comprehensive list of affected services posted on the Ohio Department of Medicaid website.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Medical Policies and Clinical Utilization Management Guidelines update
Anthem Blue Cross and Blue Shield (Ohio/MyCare Ohio) is implementing 26 new and revised medical policies and clinical utilization management guidelines effective January 1, 2027. This comprehensive update includes new coverage criteria for gene therapies, cellular immunotherapy, advanced diagnostic testing, and surgical procedures. The policy explicitly warns that some previously covered services may now be found non-medically necessary under the revised guidelines.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield Ohio is implementing new prior authorization requirements and step therapy protocols for specialty pharmacy oncology medications effective January 1, 2027. Starting that date, providers must request prior authorization for Avgemsi (gemcitabine), Docivyx (docetaxel), and Beizray (docetaxel) before dispensing, and must follow step therapy requirements for pemetrexed, bendamustine, and docetaxel products, with preferred and non-preferred formulations designated.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Starting for dates of service on or after January 1, 2027, Carelon will require precertification or prior authorization for a set of skin graft and skin substitute codes, several transoral esophagoscopy procedures, and two neurostimulator generator codes for Anthem Blue Cross Medicare Advantage members in Ohio. The source says these services are being added to the review program to support consistent application of current clinical guidelines.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Office hours: new ordering, rendering, and prescribing (ORP) provider requirements
Ohio Medicaid is implementing new ordering, rendering, and prescribing (ORP) provider requirements effective January 1, 2027. Beginning that date, all claims for designated services (DME, laboratory, imaging, therapy, home health, hospice, dental, and transportation) must include the NPI of an actively enrolled ORP provider, and managed care entities will reject any pending or new claims with ORP NPI errors. This standardizes ORP processes across Ohio Medicaid managed care and fee-for-service programs.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Precertification/prior authorization requirement changes (September 2026 Newsletter)
Anthem Blue Cross and Blue Shield (Ohio) is implementing precertification/prior authorization requirement changes effective January 1, 2027, affecting Medicare Advantage and MyCare Ohio plans. The specific requirements are not detailed in this newsletter summary and require accessing the full policy documentation through the provided link.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Clinical Criteria updates
Anthem Ohio Medicaid/MyCare Ohio has revised six clinical criteria policies for medical drug benefits, effective January 1, 2027. These revisions affect asparagine-specific enzymes, bevacizumab, radioimmunotherapy agents, nivolumab, avelumab, and amivantamab products. Billing teams must review updated medical necessity requirements and obtain prior authorization according to separate notice guidance to avoid claim denials.
Ambetter · Effective Jan 1, 2027High impact
Ambetter from Buckeye Health Plan Billing Code Update for various HCPC H Codes: Effective 01/01/2027
Effective January 1, 2027, Ambetter from Buckeye Health Plan will discontinue coverage for 45 HCPCS H codes commonly used for behavioral health and community support services. Simultaneously, H0006 coverage will begin. The practice must identify all affected claims and implement billing workflow changes to avoid denials.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Precertification/prior authorization requirement changes
Effective January 1, 2027, Anthem Blue Cross and Blue Shield is adding prior authorization requirements for 42 billing codes across multiple specialties for MyCare Ohio Fully Integrated Dual Eligible (FIDE) plans. These codes include oncology testing (0591U), skin graft procedures (1044T-1049T, Q4383-Q4397, A2036-A2045, G0682-G0684), esophageal procedures (43192, 43201, 43210, 43236, 43497), and other advanced treatments. Claims submitted without prior authorization may be denied for payment.
CareSource · Effective Jan 1, 2027High impact
[Ohio] OAC Rule 5160-1-17.9 Ordering, Referring and Prescribing Providers
Starting January 1, 2027, all Ohio Medicaid claims must include the Ordering, Referring, or Prescribing (ORP) provider's NPI number or they will be denied. This affects numerous services including DME, imaging, lab work, therapies, consultations, and institutional claims.
Anthem BCBS · Effective Jan 29, 2027High impact
[Ohio] Clinical Criteria updates
Anthem Blue Cross and Blue Shield is revising 50 clinical criteria policies for medical drug benefits covering specialty medications across oncology, immunology, rare diseases, and metabolic conditions. These revised criteria will establish updated medical necessity requirements effective January 29, 2027, and apply only to medical drug benefits (not pharmacy services). Billing teams must review updated clinical criteria documentation for affected medications to ensure compliance with new authorization and coverage requirements.
Anthem BCBS · Effective Feb 1, 2027High impact
[Ohio] Reimbursement policy update: Moderate (Conscious) Sedation — Professional and Facility
Effective February 1, 2027, Anthem will stop separately reimbursing moderate sedation services (revenue codes 0371 and 0372) when billed on inpatient facility claims with room and board charges in Ohio. The payer considers these services bundled into room and board payment, consistent with CMS policy. Practices must stop billing these codes separately on inpatient UB-04 claims or face denial.
Anthem BCBS · Effective Feb 1, 2027High impact
[Ohio] New reimbursement policy: Inpatient Hospital Inclusive Services — Facility
Effective February 1, 2027, Anthem Blue Cross Blue Shield in Ohio will no longer separately reimburse certain inpatient hospital services (blood products, DME, nursing, pharmacy, therapy, radiology guidance, diagnostic services, professional services like catheter insertion and chemotherapy administration, and outpatient clinic/treatment room services) when billed on the same date as an inpatient admission. The practice must stop billing these services separately for inpatient stays or resubmit claims with appropriate bundling to avoid denials.
Anthem BCBS · Effective Feb 1, 2027High impact
[Ohio] Claims: Effective
Effective February 1, 2027, Anthem Blue Cross and Blue Shield will not process claims for Ohio Medicaid and MyCare Ohio members from providers who are not registered and active in ODM's Provider Network Management (PNM) system. Your practice must verify enrollment status, confirm active status, and ensure all demographic and enrollment information is current in PNM before the deadline to avoid claim denials and service interruptions.
Anthem BCBS · Effective Feb 1, 2027High impact
[Ohio] Specialty pharmacy updates — November 2026
Anthem Blue Cross and Blue Shield (Ohio) is implementing multiple specialty pharmacy utilization management updates effective on staggered dates: step therapy requirements for denosumab biosimilars effective November 1, 2026, and prior authorization, quantity limits, site-of-care restrictions, and clinical criteria revisions for 24 specialty medications effective February 1, 2027. Billing teams must update systems to enforce these requirements for affected HCPCS and CPT codes to avoid claim denials.
Anthem BCBS · Effective Feb 1, 2027High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective for dates of service on or after February 1, 2027, the listed codes will require precertification or prior authorization through Carelon Medical Benefits Management for Anthem Blue Cross and Blue Shield Commercial plans in Ohio. The added codes cover full-thickness skin harvest and autologous heterogeneous skin-construct graft application, a long list of skin substitute products, and neurostimulator generators (C1826 and C1827). These services are being added to the review program to support consistent application of current clinical guidelines and evidence-based coverage criteria.
Anthem BCBS · Effective Feb 1, 2027High impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective February 1, 2027, Anthem Blue Cross and Blue Shield (Ohio) is adding 21 esophagogastroduodenoscopy (EGD) procedure codes to the prior authorization/precertification requirement list through Carelon Medical Benefits Management. All EGD procedures—both transnasal and transoral approaches with various therapeutic interventions—will now require pre-authorization before service delivery to ensure alignment with current clinical guidelines and evidence-based coverage criteria.
Ohio Medicaid · Effective Nov 8, 2026Medium impact
5160-10-29 - DMEPOS: insulin pumps. (Amend/Final File)
Ohio Medicaid (DMEPOS rule 5160-10-29) amended its insulin pump coverage policy. Two separate amendments are documented: one effective 2026-06-08 (now expired as of 2026-11-08) and a current amendment effective 2026-11-08. The billing team must verify current applicability with the Ohio Department of Medicaid, as the source does not specify what clinical or billing changes were made.
Ohio Medicaid · Effective Nov 16, 2026Medium impact
5160-1-60.2 - Direct reimbursement for out-of-pocket expenses incurred for medicaid covered services during approved eligibility periods. (Amend/Original File)
Ohio Department of Medicaid has filed an amendment to rule 5160-1-60.2 governing direct reimbursement for out-of-pocket expenses incurred for Medicaid-covered services during approved eligibility periods. The amendment is scheduled to become effective on November 16, 2026. The specific policy modifications are not detailed in the filing notice, so the billing team should obtain the full amended rule text to identify what operational or reimbursement changes apply.

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[Ohio] Updates to Carelon Medical Benefits Management Clinical Appropriateness Guidelines

[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

5160-1-17.51 - Suspension of medicaid provider claims payments during a pending audit or investigation. (New/Original File)

[Ohio] Medical Policies and Clinical Utilization Management Guidelines update

[Ohio] Include anatomical modifiers on outpatient facility claims

[Ohio] Review Excludes1 coding before submitting claims

[Ohio] Avalon Policy Updates

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

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

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

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

[Ohio] Specialty pharmacy updates

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

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

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

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (September 2026 Newsletter)

[Ohio] Clinical Criteria updates

[Ohio] Use modifier 25 when billing eligible E&M services with XXX procedures

[Ohio] 2027 Medicare formulary changes: Prepare now for

[Ohio] National accounts: 2027 standard prior authorization requirements

[Ohio] Specialty pharmacy precertification list expands

[Ohio] October 2026 Provider Newsletter

[Ohio] Prior authorization requirement changes (October ​2026 Newsletter)

[Ohio] Reimbursement policy update: Maternity Services coding changes (October 2026 Newsletter)

[Ohio] Medical Policies and clinical guidelines updates

[Ohio] Post-acute care authorization process changes

[Ohio] National accounts: 2027 standard prior authorization requirements

[Ohio] Check Present on Admission indicators to support accurate claim processing

[Ohio] Enhancing claims accuracy: expansion of inpatient high-impact DRG submissions with full medical records (October 2026 Newsletter)

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (October 2026 Newsletter)

New oncology prior authorization code updates

Ohio Medicaid: Include ORP NPI to avoid denials

[Ohio] Medical Policies and Clinical Utilization Management Guidelines update

[Ohio] Specialty pharmacy updates

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Ohio] Office hours: new ordering, rendering, and prescribing (ORP) provider requirements

[Ohio] Precertification/prior authorization requirement changes (September 2026 Newsletter)

[Ohio] Clinical Criteria updates

Ambetter from Buckeye Health Plan Billing Code Update for various HCPC H Codes: Effective 01/01/2027

[Ohio] Precertification/prior authorization requirement changes

[Ohio] OAC Rule 5160-1-17.9 Ordering, Referring and Prescribing Providers

[Ohio] Clinical Criteria updates

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

[Ohio] New reimbursement policy: Inpatient Hospital Inclusive Services — Facility

[Ohio] Claims: Effective

[Ohio] Specialty pharmacy updates — November 2026

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

5160-10-29 - DMEPOS: insulin pumps. (Amend/Final File)

5160-1-60.2 - Direct reimbursement for out-of-pocket expenses incurred for medicaid covered services during approved eligibility periods. (Amend/Original File)

[Ohio] Prior authorization requirement changes (October 2026 Newsletter)