What insurance policy changes affect Puerto Rico providers?

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

How often are Puerto Rico 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 Puerto Rico insurance policy changes?

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

PAYER POLICY CHANGES

Puerto Rico Insurance & Medicaid Policy Updates

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

Humana · Effective Oct 1, 2026High impact
Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
Humana · Effective Oct 1, 2026High impact
Bariatric Surgery - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage bariatric surgery coverage policy (HUM-1020-005) effective October 1, 2026, that outlines coverage determinations, limitations, and coding requirements for various bariatric procedures. The policy applies Humana's Medicare Advantage coverage standards and references applicable MAC Local Coverage Determinations by geographic jurisdiction, with specific rules varying by state and MAC region.
Humana · Effective Sep 1, 2026High impact
Spinal Fusion Surgery - Medicare Advantage (Revised)
This is a revised Medicare Advantage medical coverage policy for spinal fusion surgery (effective 09/01/2026) that consolidates coverage determination, limitations, coding information, and evidence summaries for cervical, lumbar, and thoracic spinal fusion procedures. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) across geographic jurisdictions and outlines covered procedures including traditional fusion, minimally invasive approaches (DLIF, XLIF, MITLIF), sacroiliac joint fusion, and interlaminar fusion techniques. Billing teams must align claims submission with the applicable MAC LCD based on patient location and ensure procedures meet specific medical necessity criteria outlined in the referenced determinations.
Humana · Effective Sep 1, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for Benign Prostatic Hyperplasia treatments effective September 1, 2026. The policy outlines coverage determinations for multiple BPH treatment modalities including surgical procedures (TURP, prostatectomy, laser therapies), temporary implanted devices, stents, and diagnostic testing. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) that vary by geographic jurisdiction, requiring billing teams to verify applicable coverage rules based on patient location.
Humana · Effective Sep 1, 2026High impact
Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)
Humana Medicare Advantage has revised its Ambulatory Cardiac Monitoring Devices policy effective September 1, 2026. The policy provides updated coverage guidance for various cardiac monitoring technologies (Holter monitors, patch recorders, external loop monitors, implantable loop recorders, and mobile cardiac outpatient telemetry) with MAC-specific coverage determinations by geographic jurisdiction. The policy document appears incomplete but establishes that medical necessity determinations will follow applicable NCDs and LCDs based on the member's jurisdiction.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage coverage policy for neuroablative techniques used to treat chronic pain, effective 08/06/2026. The policy defines coverage criteria, eligible procedures (including radiofrequency ablation, cryoablation, chemical neurolysis, and specialized devices like Intracept), and references MAC-specific LCDs and billing codes by geographic jurisdiction. Billing teams must verify applicable MAC guidelines for their state and ensure claims comply with local coverage determinations.
Humana · Effective Aug 6, 2026High impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy on neuroablative techniques for chronic pain management, effective 08/06/2026. The policy defines covered denervation procedures (radiofrequency ablation, cryoablation, facet denervation, basivertebral nerve ablation, and others) and references MAC-specific LCDs and NCDs that vary by geographic jurisdiction. Billing teams must verify applicable MAC requirements for their region before processing claims for these procedures.
Humana · Effective Aug 3, 2026High impact
Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy on genetic testing for hereditary cancer syndromes, effective August 3, 2026. The policy establishes coverage guidelines for germline genetic testing across multiple cancer types (melanoma, gastric cancer, neuroendocrine tumors, renal cell carcinoma, and others) and references specific MAC-based Local Coverage Determinations (LCDs) that vary by geographic jurisdiction. Billing teams must verify applicable MAC jurisdiction and LCD requirements before processing claims.
Humana · Effective Aug 3, 2026High impact
Breast Reconstruction - Medicare Advantage (Revised)
Humana Medicare Advantage has revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
Humana · Effective Aug 3, 2026High impact
Breast Excision and Mastectomy - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its Breast Excision and Mastectomy policy (HUM-1254-009) effective 08/03/2026. This revised policy clarifies coverage criteria for breast lesion excisions (CPT 19120, 19125), partial mastectomies (CPT 19301, 19302), and gynecomastia mastectomy (CPT 19300) across multiple MAC jurisdictions. The policy establishes specific medical necessity criteria based on biopsy results, lesion characteristics, and anatomical considerations, and applies jurisdiction-specific Local Coverage Determinations (LCDs) for Medicare Administrative Contractors.
Humana · Effective Aug 3, 2026High impact
Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)
This is a comprehensive Medicare Advantage policy for Benign Prostatic Hyperplasia (BPH) treatments that became effective on August 3, 2026. The policy outlines coverage for multiple surgical and minimally invasive treatment modalities including TURP, laser therapies, temporary implanted devices, and stents, with specific coverage determinations varying by MAC jurisdiction. Billing teams must verify applicable MAC-specific LCDs and NCDs by geographic location before processing BPH treatment claims.
Humana · Effective Nov 1, 2026Medium impact
Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)
Humana Medicare Advantage revised its neuroablative techniques for chronic pain policy effective 11/01/2026. The policy update describes coverage criteria, limitations, and coding guidance for multiple denervation procedures (radiofrequency ablation, cryotherapy, facet denervation, basivertebral nerve ablation, and other neuroablative techniques). The practice must verify applicable MAC LCDs by geographic jurisdiction, obtain prior authorization as required, and ensure claims are submitted with correct coding and documentation.
Humana · Effective Oct 1, 2026Medium impact
Low Frequency, Noncontact, Nonthermal Ultrasound for Wound Care - Medicare Advantage (Revised)
This is a revised Medicare Advantage policy for low frequency, noncontact, nonthermal ultrasound (MIST Therapy) for wound care, effective October 1, 2026. The policy clarifies medical necessity criteria across multiple MAC jurisdictions, requiring that standard wound care demonstrate no improvement or be contraindicated before this therapy is covered. Billing teams must ensure claims include proper documentation of failed standard care and route requests through applicable regional MACs.
Humana · Effective Sep 1, 2026Medium impact
Psychiatric Inpatient Hospitalization - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its Psychiatric Inpatient Hospitalization policy (HUM-9000-004) effective September 1, 2026. The policy reinforces the two-midnight benchmark for admission coverage and clarifies that psychiatric inpatient care must meet medical necessity standards based on complex medical factors. Billing teams must ensure claims documentation supports the two-midnight requirement and align with applicable MAC Local Coverage Determinations by geographic jurisdiction.
Humana · Effective Aug 30, 2026Medium impact
Molecular Diagnostic Assays and Breath Testing for Transplant Rejection - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its policy on molecular diagnostic assays and breath testing for transplant rejection, effective 08/30/2026. This policy establishes coverage criteria and references for gene expression profiling tests, antigen-specific T-cell function assays, breath testing (BMAC/Heartsbreath), and donor-derived cell-free DNA tests used to monitor organ transplant recipients. Billing teams must verify MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction, as coverage and coding requirements vary significantly by region.
Humana · Effective Aug 3, 2026Medium impact
Liquid Biopsy - Medicare Advantage (Revised)
Humana Medicare Advantage has updated its Liquid Biopsy coverage policy (Policy HUM-1151-014), effective 08/03/2026. This policy establishes coverage criteria for liquid biopsy tests (blood-based biomarker analysis for cancer detection and treatment monitoring) across multiple jurisdictions under Medicare Administrative Contractors. The policy requires medical necessity documentation and adherence to MAC-specific Local Coverage Determinations, with coverage determined through analytical/clinical validity standards and DEX Registry evaluation where CMS guidance is absent.
Humana · Effective Mar 2, 2026Medium impact
Advanced Imaging of the Head and Neck - Medicare Advantage (Revised)
Humana has revised their Medicare Advantage policy for advanced imaging of the head and neck, establishing specific medical necessity criteria for MRA and MRI procedures. The policy provides jurisdiction-specific coverage determinations and clarifies when high-risk intracranial aneurysmal screening MRA is considered medically necessary.
Humana · Effective Feb 2, 2026Medium impact
Psychological and Neuropsychological Testing - Medicare Advantage (New)
Humana has released a new Medicare Advantage medical coverage policy for psychological and neuropsychological testing, establishing coverage criteria and billing guidelines for related CPT codes. This policy references multiple Medicare Administrative Contractor (MAC) Local Coverage Determinations across different states to determine medical necessity requirements.
UnitedHealthcare · Identified Jan 12, 2026Medium impact
Credentialing Plan State and Federal Regulatory Addendum: Additional State and Federal Credentialing Requirements
State insurance and HMO regulations apply to Commercial, Medicare and Medicaid products and health plans sold in each state, and the federal Medicare participation rules apply to all Medicare and Medicare/Medicaid dual eligible products. Examples of state timelines include 60 calendar days to conclude credentialing in Arizona, 60 calendar days for physicians in Colorado, and no more than 90 days for initial credentialing in New Jersey after receipt of a complete application. Maryland and North Carolina restrict requests for information beyond the uniform credentialing form, and federal rules require the information verified for a credentialing decision to be no more than 180 calendar days old at the time of the Credentialing Committee decision. California rules take effect January 1, 2027 for 90-day determinations and January 1, 2028 for use of the CAQH credentialing form.

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

Bariatric Surgery - Medicare Advantage (Revised)

Spinal Fusion Surgery - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Ambulatory Cardiac Monitoring Devices - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Genetic Testing for Hereditary Cancer - Medicare Advantage (Revised)

Breast Reconstruction - Medicare Advantage (Revised)

Breast Excision and Mastectomy - Medicare Advantage (Revised)

Benign Prostatic Hyperplasia Treatments - Medicare Advantage (Revised)

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

Low Frequency, Noncontact, Nonthermal Ultrasound for Wound Care - Medicare Advantage (Revised)

Psychiatric Inpatient Hospitalization - Medicare Advantage (Revised)

Molecular Diagnostic Assays and Breath Testing for Transplant Rejection - Medicare Advantage (Revised)

Liquid Biopsy - Medicare Advantage (Revised)

Advanced Imaging of the Head and Neck - Medicare Advantage (Revised)

Psychological and Neuropsychological Testing - Medicare Advantage (New)

Credentialing Plan State and Federal Regulatory Addendum: Additional State and Federal Credentialing Requirements