What insurance policy changes affect Oregon providers?

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

How often are Oregon 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 Oregon insurance policy changes?

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

PAYER POLICY CHANGES

Oregon Insurance & Medicaid Policy Updates

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

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.
Oregon Health Plan · Effective Jan 1, 2027High impact
Breast and Cervical Cancer Treatment Program Updates Related to Federal Changes
Oregon Health Plan (OHP) is implementing three changes to the Breast and Cervical Cancer Treatment Program (BCCTP) due to federal requirements: (1) noncitizen immigration status eligibility changes effective October 1, 2026 (already in effect); (2) transition of Healthier Oregon members to OHP Open Card starting January 1, 2027, requiring providers to bill OHA directly instead of CCOs; and (3) retroactive coverage reduction from three months to two months for newly eligible BCCTP members effective January 1, 2027.
Oregon Health Plan · Effective Jan 1, 2027High impact
Oregon Health Authority (OHA) expectations for Health-Related Social Needs (HRSN) service transitions for Healthier Oregon members
Effective January 1, 2027, approximately 102,000 Healthier Oregon members will transition from Coordinated Care Organizations (CCOs) to OHP Open Card (managed by Acentra). CCOs must process HRSN (Health-Related Social Needs) service requests on specific timelines through December 31, 2026, then transfer authorization responsibilities to Acentra. This is NOT a service termination—HRSN services will continue uninterrupted under the new plan.
Oregon Health Plan · Effective Jan 1, 2027High impact
Changes to teledentistry codes D9995 and D9996 effective Jan. 1, 2027
Effective Jan. 1, 2027, Oregon Health Authority will discontinue additional compensation for teledentistry add-on codes D9995 and D9996. These codes will pay $0 for fee-for-service claims (except as encounters for safety net clinics), though reimbursement for the actual clinical services delivered during telehealth encounters will continue. Providers must continue billing these codes with appropriate Place of Service codes for documentation purposes, but should not expect separate telehealth fees.
Oregon Health Plan · Effective Jan 1, 2027High impact
Anticipated Impacts of H.R.1 and other federal changes on Oregon’s CCOs
Under H.R.1 and a September 2025 CMS policy update, Healthier Oregon members who are enrolled with coordinated care organizations (CCOs) must move to OHP Open Card, a fee-for-service model, by January 1, 2027, affecting over 100,000 members. H.R.1 also restricts which lawfully residing non-citizens can receive federally funded Medicaid, CHIP and Marketplace subsidies, and it expands state authority to impose Medicaid copayments beginning October 2028. These changes will affect CCO operations, member outreach, billing and encounter reporting, and contractual obligations.
Oregon Health Plan · Effective Jan 1, 2027High impact
Notice of Intent – OHA will submit Oregon’s Medicaid Phase-out Plan for the Waiver Authority Related to the Prioritized List
Oregon will phase out its 1115 waiver authority for the Prioritized List by January 1, 2027. Covered services will then be defined by categories of services in the state plan, with the Prioritized List guiding medical necessity policy, so coverage decisions will be based on medical necessity rather than on whether a treatment-condition pair sits above or below the funding line. OHA estimates a 0.7% increase in 2027 CCO capitation rates to reflect coverage of some services previously not covered.
Oregon Health Plan · Effective Jan 1, 2027Medium impact
Healthier Oregon Transition Data Guidance for Prior Authorizations
Oregon's Office of Health Policy (OHA) directed coordinated care organizations (CCOs) to submit prior authorization data for Healthier Oregon members transitioning to the Oregon Health Plan Open Card program, covering approved prior authorizations for prescription, medical, behavioral and oral health services to be rendered on or after Jan. 1, 2027, plus program exception approvals. Practices in Oregon that serve these members should expect prior authorizations to be entered into fee-for-service claims processing on the dates listed, so billing staff should confirm which active authorizations carry 2027 effective dates and that claims reference them correctly.
Oregon Health Plan · Effective Jan 1, 2027Medium impact
Health Related Social Needs (HRSN) Data Submission Guidance for Healthier Oregon Transition of Care
Oregon's Medicaid Division requires Coordinated Care Organizations (CCOs) to submit Health Related Social Needs (HRSN) data for members transitioning from CCO enrollment to the Open Card fee-for-service program effective January 1, 2027. CCOs must submit member roster files and supporting documentation on four staggered dates between November 2, 2026, and January 6, 2027, using specific file naming conventions via the Actuarial Managed File Transfer (MFT) server.
Oregon Health Plan · Effective Jan 1, 2027Medium impact
Notice of intent: OHA will amend the Medicaid State Plan to comply with several provisions of the Working Families Tax Cut Legislation
Oregon Health Authority will submit State Plan Amendments to comply with Working Families Tax Cut (WFTC) changes to Medicaid and CHIP effective January 1, 2027. The changes add community engagement (work) requirements as a condition of eligibility for the ACA adult expansion population, require eligibility redeterminations every 6 months for ACA adults, shorten the retroactive eligibility period for applications made on or after January 1, 2027, and require a process to regularly obtain address information from a reliable data source. The amendments will not change any coverage or benefits or how Oregon Health Plan provides EPSDT services, and written comments are due by 5 p.m. November 13, 2026.
Oregon Health Plan · Effective Jan 1, 2027Medium impact
Non-Emergency Medical Transportation Data Guidance for the Healthier Oregon Transition
Oregon Health Authority (OHA) requires Coordinated Care Organizations (CCOs) to submit Non-Emergency Medical Transportation (NEMT) data for Healthier Oregon members transitioning to the Open Card program effective January 1, 2027. CCOs must provide member access accommodation notes (language needs, directions, mobility accommodations, etc.) to OHA by October 9, 2026, with ongoing submissions for new NEMT users through January 29, 2027. This data transfer ensures Open Card NEMT brokerages can process service requests starting October 1, 2026.
Oregon Health Plan · Effective Jan 1, 2027Medium impact
Notice of intent: OHA will amend the Medicaid State Plan to renew the 1915(i) state plan option - Comments due May 29, 2026
Oregon Health Authority will submit a State Plan Amendment to renew the 1915(i) Home and Community-Based Services state plan option, effective January 1, 2027. The 1915(i) HCBS state plan option must be renewed and approved every 5 years. The renewal has no significant changes to program eligibility, Community-Based Integrated Supports, Psychosocial Rehabilitation, In-Home Personal Care, Residential Habilitation, or reimbursement methodologies. Public comments were due by 5 p.m. Friday, May 29, 2026, and the estimated Total Fund 2027 cost is $146,609,320.
Oregon Health Plan · Effective Jan 1, 2027Medium impact
Notice of intent: OHA will add clinical coverage criteria to the Medicaid State Plan.
Oregon Health Authority will submit a State Plan Amendment to add clinical coverage criteria to the Medicaid State Plan, effective January 1, 2027. The change supports Oregon's transition away from the 1115 waiver authority for the Prioritized List of Health Services. The Health Evidence Review Commission will continue to define medically necessary services and clinical coverage criteria, and OHA will have a process to assess medical necessity when requested services do not meet clinical coverage criteria. Public comments were due by 5 p.m. Friday, June 26, 2026.
Oregon Health Plan · Effective Jul 1, 2027Medium impact
Reconciling of The ASAM Criteria, Third Edition and The ASAM Criteria, Fourth Edition – Updated Timeline
Oregon Health Authority has extended the deadline for substance use disorder treatment providers to comply with The ASAM Criteria, Fourth Edition from the original date to July 1, 2027. Providers can continue using Third Edition criteria until then, and licensing renewals before July 2027 will maintain previously approved ASAM levels of care.
Oregon Health Plan · Effective Jul 1, 2027Medium impact
Rulemaking for Board-Registered Behavioral Health Associates
Oregon is implementing a rule requiring board-registered behavioral health associates to work for a Certificate of Approval (COA) holding agency to bill Medicaid services. The requirement was delayed from July 1, 2026 to July 1, 2027 due to high volume of COA applications.
Oregon Health Plan · Effective Jan 1, 2027Low impact
Guidance for Developing Local HR1 Resource Lists
Oregon's Medicaid Division (OHA) is directing Coordinated Care Organizations (CCOs) to develop and share local resource lists to help members comply with new federal HR1 work or activity requirements effective January 1, 2027. This is an administrative guidance memo for CCO operations, not a direct billing policy change. Medical billing teams should be aware that members may need documentation support for work, education, or volunteering activities to maintain OHP coverage.
Oregon Health Plan · Effective Jan 31, 2027Low impact
New due date for pre-release Reentry services readiness plan
Oregon Health Authority (OHA) has extended the due date for Coordinated Care Organizations (CCOs) to submit their pre-release Reentry health care services readiness plan from January 1, 2027 to January 31, 2027. This is a plan contract deliverable extension based on anticipated low demand for pre-release services. OHA will provide the readiness plan template by November 2, 2026.
Regence BlueShield · Effective Nov 1, 2026High impact
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder
This is a medical policy for Applied Behavior Analysis (ABA) treatment of Autism Spectrum Disorder, effective November 1, 2026. The policy establishes coverage criteria requiring prior authorization for certain member contracts, documented diagnosis by qualified providers, individualized treatment plans with specific clinical documentation, and ongoing progress monitoring. Billing teams must verify which member contracts require prior auth, obtain authorization before services begin, and ensure claims include required clinical documentation to support medical necessity.
Oregon Health Plan · Effective Nov 1, 2026High impact
Single standard prior authorization request process to begin Nov. 1, 2026
Effective November 1, 2026, Oregon Health Authority (OHA) will consolidate Behavior Rehabilitation Services (BRS) prior authorization into a single standard process, eliminating preliminary, retroactive, and reauthorization PA types. The review timeline is shortened from 10 business days to 7 calendar days, with an optional 14-day pend period for additional information requests. Providers must submit only standard PA requests after October 31, 2026, or risk claim denials.
Regence BlueShield · Effective Nov 1, 2026High impact
Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder
This is a new medical policy effective November 1, 2026, establishing coverage criteria for Applied Behavior Analysis (ABA) therapy in the treatment of Autism Spectrum Disorder. The policy requires prior authorization, detailed individualized treatment plans, certified provider supervision, and documented functional progress for initial assessment, initiation, and continuation of ABA services. Billing teams must prepare systems now to implement preauthorization workflows and documentation requirements before the November 2026 effective date.
Oregon Health Plan · Effective Oct 27, 2026High impact
1915(i) Community Based Integrated Supports (CBIS) Authorization Process
Effective October 27, 2026, Oregon Health Authority is transitioning 1915(i) Community Based Integrated Supports (CBIS) billed under H0046 from Prior Authorization (PA) to Plan of Care (POC) authorization in MMIS. All existing PAs will end October 26, 2026, with remaining approved services automatically transferred to POC format starting October 27, 2026. New referrals will be entered directly as POC after IQA approval through the PCSP.
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.
Oregon Health Plan · Effective Oct 1, 2026High impact
Fee-for-Service Hospice Rates Effective Oct. 1, 2026
Oregon Medicaid updated hospice fee-for-service rates effective October 1, 2026, introducing a critical billing distinction: revenue code 651 applies to routine home care (RHC) days 1-60, while new revenue code 650 applies to RHC days 61 and beyond. Providers must track hospice election days carefully for readmissions and ensure compliance with federal quality reporting requirements to receive full Medicaid rates; non-compliant providers will receive lower reimbursement.
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.
Oregon Health Plan · Effective Oct 1, 2026High impact
Rulemaking for Board-Registered Behavioral Health Associates
Starting October 1, 2026, board-registered behavioral health associates in Oregon must work for organizations with a Certificate of Approval (COA) from OHA to bill Medicaid. Associates working independently will no longer be able to bill Medicaid directly unless they work in HRSA clinics or school settings.
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.
Oregon Health Plan · Effective Aug 1, 2026High impact
Reimbursement for nitrous oxide during in-office medical procedures effective Aug. 1, 2026
Effective August 1, 2026, Oregon Health Plan (OHP) now covers nitrous oxide for use during in-office medical procedures. Providers must bill using CPT code 01999 with modifier QS at a reimbursement rate of $44.08. CCOs must update claims processing systems to recognize and reimburse for this service.
Oregon Health Plan · Effective Jul 31, 2026High impact
Change to interRAI Community Mental Health (CMH) assessment tool effective July 31, 2026
Oregon Health Authority is replacing the Level of Service Inventory (LSI) assessment tool with the interRAI Community Mental Health (CMH) instrument for determining 1915(i) HCBS program eligibility effective July 31, 2026. This change affects service eligibility determination and residential rate calculations. The LSI will continue for Young Adults in Transition (YAT) Homes serving individuals under 21.
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.
Oregon Health Plan · Effective Jul 1, 2026High impact
Fee-for-service nursing facility rates effective July 1, 2026
Oregon Health Authority updated fee-for-service hospice payment rates effective July 1, 2026, including new nursing facility room and board bundled rates and revised revenue codes for routine home care billing. Revenue code 650 (Days 61+) replaces previous coding for extended hospice stays, and providers must include the nursing facility's Oregon Medicaid provider number on all claims. Rates vary by geographic Cost-Based Statistical Area (CBSA).
Oregon Health Plan · Effective Jun 30, 2026High impact
Board-Registered Behavioral Health Associates and Mental Health Interns
Oregon Health Plan (Medicaid) will require Board Registered Behavioral Health Associates and Mental Health Interns to work for organizations with Certificate of Approval (COA) to continue billing OHP after June 2026. Current providers can continue direct billing until June 2026, after which they must become fully licensed or work for COA-certified organizations.
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.
Oregon Health Plan · Effective Jun 1, 2026High impact
New process for non-response to licensing information requests, effective June 1, 2026
Oregon Medicaid will auto-terminate mental health and substance use disorder providers who fail to respond to licensing information requests. SUD providers face termination starting June 1, 2026, and MH providers starting July 1, 2026.
Providence Health Plan · Effective Jun 1, 2026High impact
Special Alert June 2026 - UPDATE Part 2 - Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes
Providence Health Plan implemented four coding and reimbursement policy changes effective June 1 and July 1, 2026: (1) rescinded the inpatient sepsis DRG length-of-stay edit; (2) will deny critical care services (99291/99292) billed in the ED when patients are discharged home; (3) will deny surgical procedures (CPT 10000-69999) missing required anatomical modifiers (RT, LT, E1-E4, etc.); and (4) will no longer reimburse additional units for anesthesia physical status modifiers P3, P4, P5 on commercial plans. These changes require immediate updates to billing logic, provider documentation requirements, and claim submission processes.
Providence Health Plan · Effective Jun 1, 2026High impact
Special Alert April 2026 - Alert for 6.1 Coding and Reimbursement Policy Changes
Providence Health Plan is implementing four new coding and reimbursement policies effective June 1, 2026: (1) denying sepsis DRG claims (871-872) with <3-day stays discharged to home; (2) denying critical care codes (99291-99292) billed in ED when discharged to home; (3) denying surgical procedures missing required anatomical modifiers; and (4) eliminating additional reimbursement units for anesthesia physical status modifiers P3, P4, P5 on commercial plans. These changes require immediate billing system updates and provider documentation reviews to prevent claim denials.
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).
Regence BlueCross BlueShield of Oregon · Effective May 6, 2026High impact
Legacy Health negotiations
Legacy Health has returned to in-network status for Regence health plan members in Oregon and Southwest Washington effective immediately (as of May 6, 2026). All claims from Legacy Health providers during the out-of-network period will be reprocessed as in-network. Billing teams must update provider directories and ensure claims are submitted with in-network status going forward.
Oregon Health Plan · Effective Apr 21, 2026High impact
Billing guidance for obstetric services provided by FQHCs and RHCs
Oregon Health Authority requires FQHCs and RHCs to bill specific obstetric visit codes (0500F, 0502F, 0503F) individually within global obstetric bundles starting April 21, 2026, to enable accurate encounter data matching and supplemental wraparound payment processing. CCOs must pay these codes at $0.00 and report them to OHA. Additionally, retroactive billing for dates of service October 1, 2024 through April 20, 2026 is permitted to resolve past payment discrepancies.
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.
Providence Health Plan · Effective Mar 15, 2026High impact
Special Alert December 2025 - Taxonomy Requirements
Effective March 15, 2026, Providence Health Plan (PHP) and Providence Health Assurance (PHA) will require taxonomy codes on all provider-submitted Medicare and Commercial claims. Claims submitted with incorrect or missing taxonomy codes will be denied. Providers must ensure their taxonomy codes are accurately registered and included in all claim submissions.
Providence Health Plan · Effective Mar 15, 2026High impact
Special Alert December 2025 - Taxonomy Requirements
Effective March 15, 2026, Providence Health Plan (PHP) and Providence Health Assurance (PHA) will require taxonomy codes on all provider-submitted Medicare and Commercial claims. Claims submitted with missing or incorrect taxonomy codes will be denied. Providers must ensure their taxonomy codes are registered with CMS and included in all claim submissions.
Providence Health Plan · Effective Mar 4, 2026High impact
Special Alert March 2026 - Implementation of Multiple Surgery Reduction (MSR) Rules for Endoscopic Procedures Billed by Ambulatory Surgery Centers (ASCs)
Effective March 4, 2026, Providence Health Plan implemented Multiple Surgery Reduction (MSR) rules for endoscopic procedures billed by Ambulatory Surgery Centers (ASCs). ASCs must now apply special payment rules: the highest-valued endoscopy in the same family is paid at 100%, with subsequent procedures paid at the difference between procedure and base code amounts; endoscopies from different families follow CMS MSR (100% for highest, 50% for additional); and combined endoscopy/non-endoscopy procedures follow respective reduction rules. This change aligns ASC adjudication with national CMS policy and will result in reduced reimbursement for multiple procedures.

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December 2026 Drug List Change Notification (Commercial)

Breast and Cervical Cancer Treatment Program Updates Related to Federal Changes

Oregon Health Authority (OHA) expectations for Health-Related Social Needs (HRSN) service transitions for Healthier Oregon members

Changes to teledentistry codes D9995 and D9996 effective Jan. 1, 2027

Anticipated Impacts of H.R.1 and other federal changes on Oregon’s CCOs

Notice of Intent – OHA will submit Oregon’s Medicaid Phase-out Plan for the Waiver Authority Related to the Prioritized List

Healthier Oregon Transition Data Guidance for Prior Authorizations

Health Related Social Needs (HRSN) Data Submission Guidance for Healthier Oregon Transition of Care

Notice of intent: OHA will amend the Medicaid State Plan to comply with several provisions of the Working Families Tax Cut Legislation

Non-Emergency Medical Transportation Data Guidance for the Healthier Oregon Transition

Notice of intent: OHA will amend the Medicaid State Plan to renew the 1915(i) state plan option - Comments due May 29, 2026

Notice of intent: OHA will add clinical coverage criteria to the Medicaid State Plan.

Reconciling of The ASAM Criteria, Third Edition and The ASAM Criteria, Fourth Edition – Updated Timeline

Rulemaking for Board-Registered Behavioral Health Associates

Guidance for Developing Local HR1 Resource Lists

New due date for pre-release Reentry services readiness plan

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

Single standard prior authorization request process to begin Nov. 1, 2026

Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder

1915(i) Community Based Integrated Supports (CBIS) Authorization Process

October 2026 Drug List Change Notification (Commercial)

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

Fee-for-Service Hospice Rates Effective Oct. 1, 2026

Bariatric Surgery - Medicare Advantage (Revised)

Rulemaking for Board-Registered Behavioral Health Associates

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)

Reimbursement for nitrous oxide during in-office medical procedures effective Aug. 1, 2026

Change to interRAI Community Mental Health (CMH) assessment tool effective July 31, 2026

Breast Imaging - Medicare Advantage (Revised)

Fee-for-service nursing facility rates effective July 1, 2026

Board-Registered Behavioral Health Associates and Mental Health Interns

June 2026 Drug List Change Notification (Commercial)

New process for non-response to licensing information requests, effective June 1, 2026

Special Alert June 2026 - UPDATE Part 2 - Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes

Special Alert April 2026 - Alert for 6.1 Coding and Reimbursement Policy Changes

May 2026 Drug List Change Notification (Commercial)

Legacy Health negotiations

Billing guidance for obstetric services provided by FQHCs and RHCs

April 2026 Drug List Change Notification (Commercial)

Special Alert December 2025 - Taxonomy Requirements

Special Alert December 2025 - Taxonomy Requirements

Special Alert March 2026 - Implementation of Multiple Surgery Reduction (MSR) Rules for Endoscopic Procedures Billed by Ambulatory Surgery Centers (ASCs)