Policy changes from Ohio Medicaid and from Medicaid managed care plans in Ohio, with the Medicaid prior authorization lists and payer contacts we track for the state. Each item links to its public source.
Ohio Department of Medicaid filed a revised version (Amendment, effective 11/02/2026 per the filing record) of rule 5160-1-05.3, which governs payment for Medicare Part B cost sharing. The filing record shows the revision was filed 11/06/2026; the excerpt does not provide the substantive payment text, so the specific changes to cost-sharing payment cannot be identified from it.
UnitedHealthcare Community Plan of Ohio published its November 2026 Medical Benefit Drug Policy update for White Blood Cell Colony Stimulating Factors (Ohio only), labeled as a routine review with no change to coverage guidelines. The billing team should confirm the policy's current coverage criteria for Ohio Medicaid members, since the notice gives no detail on specific codes or requirements.
UnitedHealthcare Community Plan of Ohio published a November 2026 medical policy update for its Rituximab policy (Riabni, Rituxan, Ruxience, and Truxima) covering Ohio Medicaid members. The update is a routine review, and the bulletin states no change to coverage guidelines. Billing teams should note the revised policy text but no new billing or documentation steps appear in the source.
UnitedHealthcare Community Plan of Ohio published its November 2026 Medicaid medical policy update bulletin, which includes a routine review of the Nplate (romiplostim) policy for Ohio members. The bulletin states no change to coverage guidelines. Billing teams treating Ohio Medicaid members who receive Nplate should keep current coverage criteria on file and confirm the policy's effective date of 2026-12-01 in their own workflows.
Effective 2026-12-01, the Ohio Medicaid medical policy for amyloid-directed monoclonal antibodies for Alzheimer's disease now states that it applies to Leqembi (lecanemab-irmb) given by intravenous infusion by a healthcare professional. Leqembi IQLIK, the self-administered subcutaneous injection, is obtained under the pharmacy benefit unless the member-specific benefit plan document says otherwise.
UnitedHealthcare Community Plan of Ohio updated its Medical Benefit Drug Policy for Gamifant (emapalumab-lzsg) in the November 2026 medical policy update bulletin, refreshing the clinical evidence and references sections. The published update lists a Medicaid effective date of 2026-12-01 for Ohio members.
UnitedHealthcare Community Plan of Ohio published its November 2026 medical policy update bulletin, including an updated Medical Benefit Drug Policy for Brineura (cerliponase alfa) effective 2026-12-01. The update is described as a routine review with no change to coverage guidelines, so billing teams serving Ohio Medicaid members should keep existing Brineura claim workflows in place and confirm the policy text against their current payer documentation.
UnitedHealthcare Community Plan of Ohio updated its Botulinum Toxins A and B medical benefit drug policy in its November 2026 medical policy bulletin, with a stated effective date of 2026-12-01. The update is described as a routine review with no change to coverage guidelines, so the billing team should confirm current requirements for these drugs for Ohio Medicaid members and keep existing documentation and authorization workflows in place.
UnitedHealthcare Community Plan of Ohio retired its medical policy on video electroencephalographic (vEEG) monitoring and recording in its November 2026 update bulletin, so these services no longer require clinical review under that policy for Ohio Medicaid members. The retirement takes effect 2026-12-01.
UnitedHealthcare Community Plan of Ohio retired its Surgery of the Elbow medical policy for Medicaid members in Ohio, so surgery of the elbow no longer requires clinical review under that policy. Billing teams should stop routing elbow surgery requests for Ohio Community Plan members through the prior review process that this policy previously governed.
UnitedHealthcare Community Plan of Ohio updated its Outpatient Surgical Procedures – Site of Service medical policy for Ohio Medicaid members, effective 2026-12-01. Changes add a related-policy reference to the Surgery of the Wrist or Thumb policy, expand the Medical Records Documentation section to state that documentation must fully support medical necessity, be legible, kept in the patient's record and available on request, and update the definition of Poorly Controlled Hypertension and the References section.
UnitedHealthcare Community Plan of Ohio added HCPCS code L5992 to its Lower Extremity Prosthetics medical policy for Ohio Medicaid members, and updated the Clinical Evidence and References sections. The change takes effect December 1, 2026.
UnitedHealthcare Community Plan of Ohio revised its Medicaid medical policy for hearing aids and devices, effective 2026-12-01. The revision adds coverage language stating that a semi-implantable electromagnetic hearing aid for sensorineural hearing loss is proven and medically necessary for individuals who are not candidates for an air conduction hearing aid when used per FDA labeled indications, and it removes the InterQual CP: Procedures, Hearing Device, Middle Ear reference while updating the description, evidence and references sections.
UnitedHealthcare Community Plan of Ohio updated its Medicaid medical policy for extracorporeal shock wave therapy (ESWT) for musculoskeletal and soft tissue indications, with the updated policy effective 2026-12-01. The revision refreshes the clinical evidence and references sections, so billing teams should review the updated criteria before submitting ESWT claims for Ohio Community Plan members.
The Ohio Department of Medicaid has filed a new rule (5160-1-17.9) titled 'Participating and reporting-only providers' effective December 4, 2026. The source document lists only the filing metadata and does not provide the substantive text of the rule itself, making it impossible to determine what specific billing, authorization, documentation, coding, or credentialing changes apply to your practice.
Ohio Medicaid is rescinding the rule 5160-1-17.9 titled 'Ordering or referring providers' effective 12/04/2026 and replacing it with a new rule titled 'Participating and reporting-only providers.' The source document provides only the administrative filing notice and does not include the substantive policy text, so the specific operational impact cannot be determined from the information provided.
Anthem's November 2026 Ohio provider newsletter lists many updates with different effective dates, so the newsletter has no single effective date. The dated items take effect between December 1, 2026 and March 1, 2027, and none has passed yet. The main changes are Excludes1 claim review and anatomical modifiers, MyCare Ohio registration and transportation changes, Commercial sedation and inpatient reimbursement policies, and Medicare Advantage prior authorization and clinical criteria updates.
This is an educational bulletin from Anthem Blue Cross and Blue Shield (Ohio) about flu vaccine hesitancy published November 1, 2026. It provides providers with conversation strategies, evidence-based responses to vaccine concerns, and resources to improve flu vaccination rates. This is informational guidance for clinical staff, not a billing or coverage policy change.
Anthem MyCare Ohio (Ohio Medicaid managed care) clarified prior authorization requirements and timelines for long-term care/custodial care and skilled nursing facility services. Key points: the Floor to SNF program does not apply to MyCare Ohio; all authorizations are handled by the health plan (not Carelon); 2027 authorizations can be submitted immediately; retro authorizations are not allowed; and specific documentation and readmission procedures apply for bed hold days and SNF returns.
Anthem Blue Cross and Blue Shield Ohio has published an updated Provider Relations territory map effective November 1, 2026, assigning specific provider relationship representatives by county, billing agency, facility/group, and service type (DME/home healthcare/SNF, behavioral health). This is an administrative contact and routing update for Ohio Medicaid, MyCare Ohio, Commercial, and Medicare lines of business.
Anthem Blue Cross and Blue Shield Ohio Medicaid (including MyCare Ohio, excluding Full Duals) implemented an updated out-of-network request process for non-emergent services effective November 1, 2026. Providers must now submit the Anthem OON Provider Request Form with clinical documentation demonstrating why available in-network options cannot meet the member's needs; UM will review requests and identify up to three in-network alternatives before approving out-of-network care.
Effective January 1, 2027, Anthem Blue Cross and Blue Shield will require prior authorization before rendering specialized and bariatric transportation services for MyCare Ohio members. Claims must be billed with HCPCS code A0999 appended with modifier U1, U2, or U3 (based on weight category) and include the approved authorization number. Annual payment caps will apply by transportation category ($100,000–$250,000).
Anthem Blue Cross and Blue Shield Ohio Medicaid and MyCare Ohio are issuing a best practice recommendation for pediatric practices to screen parents for perinatal depression during infant well-child visits at 1, 2, 4, and 6 months using validated tools (EPDS or PHQ-9). The bulletin includes a billing reminder to consider CPT 96161 for caregiver-focused health risk assessment when documentation of the screening tool, score, interpretation, and follow-up plan is provided.
Anthem MyCare Ohio clarified that G0156 home health aide services require prior authorization based on Ohio Medicaid State Plan medical necessity standards. Eligibility for home- and community-based (HCBS) waiver services does not automatically qualify members for G0156; claims must include supporting clinical documentation, a practitioner order, a qualifying face-to-face encounter, a signed home health plan of care, and demonstration of an independently medically necessary skilled service. This guidance became effective November 1, 2026.
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.
This is a historical prior authorization policy for intravenous iron products (Feraheme, Injectafer, Monoferric) under Humana Medicaid–Ohio, effective January 1, 2026 with a revision dated November 1, 2026. The policy requires prior authorization for these products when members have iron deficiency anemia and have had prior therapy, contraindication, or intolerance to iron dextran (Infed) and iron sucrose (Venofer). Since the effective date (January 1, 2026) and revision date (November 1, 2026) are both in the past relative to the analysis date (November 3, 2026), this policy is already in effect; no future changes are pending.
This is a historical policy document (published September 1, 2026, discovered November 3, 2026) establishing prior authorization requirements for Vyvgart and Vyvgart Hytrulo in Ohio Medicaid. The policy requires prior auth for both generalized myasthenia gravis (gMG) and CIDP (Vyvgart Hytrulo only), with specific antibody or nerve testing criteria and specialist supervision requirements. Since the effective date has passed, verify current applicability with Humana before implementing.
Humana Ohio Medicaid established a new prior authorization policy effective November 1, 2026, for pembrolizumab products (Keytruda intravenous powder, intravenous solution, and Keytruda Qlex subcutaneous solution) across 25 cancer indications. Each indication has specific clinical criteria, required combination or monotherapy regimens, biomarker requirements (CPS, PD-L1, dMMR/MSI-H, or TMB-high scores where applicable), and exclusions based on prior anti-PD-1/PD-L1 therapy. Initial and renewal approvals are granted for 6 months or as determined through clinical review.
Ohio Department of Medicaid is rescinding and replacing Rule 5160-12-08 regarding registered nurse assessment and consultation services, effective December 3, 2026. The source document does not provide the specific content of the rescission or new rule text, making it impossible to determine what coverage, billing, or documentation changes will apply.
Ohio Department of Medicaid filed an amendment to Rule 5160-12-06 regarding private duty nursing services reimbursement on 2026-11-02, effective 2026-12-03. The source document provided lists only the rule filing metadata and historical file dates without specifying the actual policy content changes, rates, codes, or requirements being amended.
The Ohio Department of Medicaid filed a new rule (5160-12-08) on registered nurse assessment and consultation services, effective December 3, 2026. The source document provided is an index listing of regulatory filings and historical actions but does not contain the actual rule text, specific billing codes, coverage criteria, or billing requirements needed to determine what your practice must do.
This Q2 2026 Humana newsletter (published April 1, 2026, discovered November 1, 2026) contains multiple effective dates spanning past, ongoing, and future actions. Key changes include: (1) New prior authorization lists effective July 1, 2026, for Medicare Advantage, Dual Eligible SNPs, and Medicaid plans; (2) Medicaid provider-administered medication PAL changes for seven states; (3) PPO members inactive since May 1, 2024, were automatically unpaneled as of March 1, 2026; (4) New claims-based attribution rules for MA products effective April 1, 2026; and (5) Published claims payment policies including a new Paper Claim Administrative Fee. The newsletter emphasizes timely prior authorization submission before services are fully furnished to avoid claim denial and retroactive authorization processing.
This Q3 2026 Humana newsletter (published July 1, 2026, discovered November 1, 2026) is historical material containing mixed-date guidance. Key items: (1) Clinical documentation for Medicare prior authorizations must be submitted at time of request to meet CMS's 7-day decision requirement—already effective January 1, 2026. (2) Enhanced real-time PA workflow for diagnostic imaging in GA, NC, SC, VA now available. (3) Medicaid medication list updates for five states. (4) New and revised claims payment policies published. (5) Informational resources on safe prescribing, obesity management, and care gap closure. Most actionable items are already in effect or operational.
CareSource Ohio Medicaid is revising eight administrative and medical policies and introducing one new reimbursement policy, all effective January 1, 2027. Changes affect esophageal brush biopsy, experimental/investigational services, gender dysphoria treatment, obstetrical care, retrospective authorization review, hospice billing, diabetes self-management training, neonatal discharge criteria, and obstetrical care reimbursement. None of these revisions impact prior authorization requirements.
CareSource Ohio Medicaid released revised pharmacy policies for 12 specialty medications effective February 1, 2027. All revised policies explicitly state 'NO' impact to prior authorization requirements, meaning current PA workflows remain unchanged for these drugs. The policy document serves as notification of policy revisions; billing teams should review the full policies online to identify any other coverage or documentation changes not summarized in this notice.
CareSource OhioRISE is implementing a new transportation benefit requirement effective November 1, 2026, mandating that a parent, legal guardian, or approved authorized adult must accompany all Ohio Medicaid and Next Generation MyCare members under 18 on every ride, with limited exceptions for parents transporting their own children, pregnant members, and emancipated minors. This is a non-clinical operational policy that does not directly affect billing codes but may impact care coordination and member transportation logistics.
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.
This is historical material: a Humana Clinical Trials Pharmacy Policy originally effective 2016-10-19, newly discovered 2026-10-28. The policy governs coverage of routine care and services costs for members enrolled in federally funded or approved clinical trials for cancer or other life-threatening illnesses, with specific eligibility criteria, exclusions, and requirements for trial approval. The revision date of 2026-10-28 reflects recent policy updates; verify current applicability with Humana's online policy portal before applying.
Anthem Blue Cross and Blue Shield has established in-network access to three Guardant Health precision oncology tests (Guardant360 Liquid, Guardant360 Tissue, and Guardant Reveal) for commercial, Medicare Advantage, and Medicaid members in Ohio. These blood-based and tissue tests support cancer diagnosis, treatment selection, and recurrence monitoring. Providers can request test kits through guardantcomplete.com/hcp/support/request-kit.
Anthem Blue Cross and Blue Shield updated its prior authorization requirements guide for Ohio Medicaid Managed Care and MyCare Ohio plans, effective October 26, 2026. This is a comprehensive reference document listing services requiring prior authorization across physical health and behavioral health categories, with specific visit limits and exceptions. Billing teams must verify that their authorization workflows align with these requirements to avoid claim denials.
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Ohio Medicaid is adding prior authorization requirements for 6 specialty pharmacy medications (immunomodulators and biosimilars) billed under the medical benefit, and implementing step therapy reviews for 10 bendamustine and pemetrexed formulations upon prior authorization initiation or renewal. Billing teams must request prior authorization for these medications on dates of service on or after December 1, 2026, and ensure NDC codes are included on all medical claims.
Ohio Department of Medicaid has filed a new rule (5160-1-17.8) regarding provider screening and application fees, effective 11/23/2026. This rule establishes or modifies the fees associated with Medicaid provider enrollment screening and applications. The billing team should verify the specific fee amounts and any changes to enrollment processes once the full rule text is available.
Ohio Department of Medicaid is rescinding the existing rule 5160-1-17.8 (Provider screening and application fee) and simultaneously filing a new version of the same rule, both effective 11/23/2026. The billing team must verify the specific changes between the rescinded and new rule versions by reviewing the full policy text to understand how provider screening and application fee requirements will change.
Ohio Department of Medicaid has refiled Rule 5160-3-18 governing the nursing facilities ventilator program. The refile was submitted on 10/22/2026 and became effective on 10/16/2026. However, the source document does not contain the actual policy text detailing what substantive changes were made to the ventilator program requirements, coverage, billing codes, or clinical operations.
This is a historical prior authorization policy for Jelmyto (mitomycin) intra-pyelocalyceal solution for low-grade upper tract urothelial cancer (LG-UTUC) treatment under Ohio Medicaid. The policy became effective January 1, 2026, and was newly discovered on October 22, 2026. The billing team should verify current applicability with Humana, as this is an older source document and the policy may have been updated since its January 2026 effective date.
Humana Medicaid Ohio established a prior authorization requirement for Izervay (avacincaptad pegol), a complement inhibitor intravitreal injection for geographic atrophy secondary to age-related macular degeneration. Coverage requires diagnosis of GA secondary to AMD and prescription by or in consultation with an ophthalmologist or retinal specialist, with approval granted for plan year duration and renewable annually.
This is a historical policy document from January 1, 2017 that was recently discovered (October 21, 2026). It establishes Humana's framework for pharmacy quantity limitations across Medicare and multiple state Medicaid programs. The policy permits quantity limits based on FDA-approved dosing, medical literature, and treatment guidelines, with exceptions available for dosage titration, compendia-supported dosages, failed trials, or individual member characteristics. The most recent revision is October 21, 2026, but no new effective date or changes are stated in this revision—verify current applicability with Humana's online policy portal.
This is historical material from a Humana Medicaid pharmacy policy originally effective June 3, 2020, revised October 21, 2026. The policy establishes that non-FDA approved medications are excluded from Humana formularies unless reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee. Coverage for approved non-FDA medications is limited to the plan year duration. No new actionable changes are indicated; verify current applicability with Humana before applying this guidance.
The Ohio Department of Medicaid has filed an amendment to Rule 5160-1-16 regarding preventive services, effective 2026-11-20. The source document does not provide specific policy content details, only filing metadata and administrative information. The billing team should obtain the full rule text and amendments to determine what specific changes apply to preventive service coverage, billing codes, or documentation requirements under Ohio Medicaid.
This is an Original File amendment to Ohio administrative rule 5160:1-2-01 governing Medicaid administrative agency responsibilities, filed on 2026-10-16. The document provides the regulatory framework for Ohio Department of Medicaid's administrative functions but does not specify substantive billing, coding, or coverage changes applicable to medical practices.
Get alerts for changes like this
Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.