What insurance policy changes affect South Dakota providers?

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

How often are South Dakota 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 South Dakota insurance policy changes?

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

PAYER POLICY CHANGES

South Dakota Insurance & Medicaid Policy Updates

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

South Dakota Medicaid · Effective Jan 1, 2027Medium impact
Summer Provider Newsletter
Starting January 1, 2027, some adults enrolled in South Dakota Medicaid Expansion (coverage codes 92, 93, 94 and 95) must show 80 hours a month of work, job training, community service, educational enrollment, or a combination of these, and the source lists exclusions to this requirement. Those enrollees will renew every 6 months instead of every 12, and retroactive coverage for all Medicaid and CHIP applicants will be limited to 1 month for Expansion-only adults and 2 months for other groups, down from 3 months. Separately, inpatient hospital claims for recipients in a South Dakota Medicaid Care Management program must include the referring provider's NPI in locator 78 or 79 when the admission is urgent or elective.
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.
South Dakota Medicaid · Effective Aug 1, 2026High impact
HMS Disallowance and Recoupment Process
South Dakota Medicaid has partnered with Health Management Systems (HMS) to conduct third-party liability and coordination of benefits reviews starting August 2026. Providers must respond to HMS claims review notices within 60 days via their online portal, or claims will be automatically recouped. Failure to register and respond will result in financial recoupment by DSS.
South Dakota Medicaid · Effective Jul 1, 2026High impact
SFY27 Reimbursement
South Dakota Medicaid is implementing comprehensive reimbursement rate increases effective July 1, 2026, including hospital methodology changes (MS-DRG to APR-DRG), FQHC alternative payment methodology, Care Connect tier rate adjustments, and 1.4% inflationary increases across professional services capped at 100% of Medicare. Billing teams must update fee schedules, verify rate changes for specific procedure codes, and align claims submission to new reimbursement methodologies.
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.
UnitedHealthcare · Effective Apr 1, 2026High impact
New DME process for select members in multiple states
Beginning April 1, 2026, Synapse Health will manage durable medical equipment (DME) ordering and fulfillment for UnitedHealthcare Medicare Advantage plans in multiple states. DME prescribers must use Synapse Health's e-prescribing portal, and DME providers must join the Synapse Health network to continue serving these members.
South Dakota Medicaid · Effective Jul 1, 2025High impact
CPT Code 92507 Billing Update Effective July 1 2025
South Dakota Medicaid is changing CPT code 92507 from a 15-minute time-based billing to a per-session billing model effective July 1, 2025. Providers can only bill one unit per member per day regardless of session length, with the new reimbursement rate set at $67.00 per session.
South Dakota Medicaid · Effective May 9, 2025High impact
Private Duty Nursing Members Providing Care
South Dakota Medicaid is prohibiting immediate family members or household members from providing Private Duty Nursing services to recipients, based on EVV data review showing violations of existing regulations. Agencies have 30 days to make alternative staffing arrangements for affected cases.
South Dakota Medicaid · Identified Sep 12, 2026High impact
Claims Work Queue Inpatient Hospitals
South Dakota Medicaid now requires inpatient hospital claims for Care Management program recipients to include the referring provider's NPI in claim locators 78 or 79. A new Claims Work Queue portal feature allows providers to submit missing NPI information within 30 days without resubmitting the entire claim; claims without the referral NPI after 30 days will be denied.
South Dakota Medicaid · Identified Sep 12, 2026High impact
Obstetrical Services Billing Changes
South Dakota Medicaid allows obstetrical services to be billed individually, per encounter and per delivery, through December 31, 2026, instead of using global codes. If any pregnancy-related service in an episode falls on or after January 1, 2027, the whole episode must be billed individually, and global claims already submitted must be voided and resubmitted within the timely filing period.
UnitedHealthcare · Identified Sep 2, 2026High impact
Hereditary cancer testing policy reminder
UnitedHealthcare is reminding providers that multigene RNA panel testing for hereditary cancer is considered unproven and will be denied. Only DNA-only hereditary cancer panels and single-gene RNA testing remain covered under applicable medical policy and prior authorization requirements.
UnitedHealthcare · Effective Nov 2, 2026Medium impact
Credentialing transitioning to CertifyOS for some states
UnitedHealthcare is transitioning credentialing activities from Onboard Pro to CertifyOS for providers in Alabama, Montana, North Dakota, South Dakota, and Wyoming, effective November 2, 2026. New credentialing submissions will continue through Onboard Pro with primary source verification completed by CertifyOS, and recredentialing for April 2027 will be managed by CertifyOS starting immediately. On November 16, 2026, providers in these states must use the CertifyOS portal for credentialing applications.
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.
Molina Healthcare · Effective Oct 26, 2026Medium impact
08-28-2026 Coming soon: New provider enrollment and credentialing portal IM IE LA OC SAC SD
Molina Healthcare is launching a new Provider Network Management Portal on October 26, 2026, that will replace email and paper-based provider enrollment and credentialing submissions for directly contracted providers. All direct provider enrollment and credentialing requests must be submitted through this new portal starting that date. This change does not affect delegated IPAs (which use D360) or Availity functionality (claims, prior auth, member panels).
Humana · Effective Oct 1, 2026Medium impact
Noninvasive Tests for Hepatic Fibrosis - Medicare Advantage (Revised)
This is a Medicare Advantage policy update (effective 10/01/2026) covering noninvasive tests for hepatic fibrosis, including imaging-based tests (MRE, qMRA) and blood-based biomarker panels (ELF, FIB-4, FibroSure, LiverFASt, NIS4, OWLiver, TruD, HepQuantDuO). The policy establishes coverage determination criteria for these tests across multiple MAC jurisdictions. The document provided is incomplete and does not contain the full coverage determination criteria, medical necessity requirements, or specific billing code guidance needed for implementation.
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.
South Dakota Medicaid · Effective Sep 18, 2026Medium impact
Medicaid Issues 9 Million
South Dakota Medicaid issued $9 million in new value-based payments to Primary Care Providers ($7M) and Care Connect providers ($2M) in September 2026, based on CY 2025 performance metrics including preventive care, screenings, well-child visits, and ER utilization. Practices should have received direct notification of payment amounts; funds must be used for quality improvement activities in preparation for the Primary Accountable Care Transformation (PACT) initiative launching January 2028.
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.
HealthPartners · Effective Aug 1, 2026Medium impact
Fast Facts Newsletter - June (Special Edition) 2026
HealthPartners has updated multiple medical policies effective immediately and August 1, 2026, including expanded cardiac monitoring coverage, new prior authorization requirements for prosthetic devices, consolidated nutritional support policies, and new reimbursement policies for single-dose vial billing and 3D imaging services.
Humana · Effective Jul 1, 2026Medium impact
Coronary CT Angiography, Fractional Flow Reserve with CT and Adjunctive Testing - Medicare Advantage (Revised)
This is a Medicare Advantage policy revision (effective 07/01/2026) for Coronary CT Angiography, Fractional Flow Reserve with CT, and adjunctive cardiac testing. The policy establishes that Humana follows applicable Local Coverage Determinations (LCDs) by MAC jurisdiction for CCTA (CPT 75574) and FFRCT (CPT 75580), with specific LCD guidance for each geographic region. Billing teams must ensure prior authorization and medical necessity documentation align with the applicable LCD in the patient's service area.
UnitedHealthcare · Effective Jun 1, 2026Medium impact
New DME process for select members in multiple states
Starting June 1, 2026, Synapse Health will manage DME ordering and fulfillment for UnitedHealthcare Medicare Advantage plans in multiple states. DME prescribers must use the Synapse Health e-prescribing portal, and DME providers must join the Synapse Health network to continue providing services.
South Dakota Medicaid · Effective May 15, 2026Medium impact
Spring Provider Newsletter
Effective May 15, 2026, the South Dakota Medicaid preferred drug list expanded to include a limited number of physician administered drugs with available biosimilar products. Hospital reimbursement is planned to move inpatient hospital payment from MS-DRG to APR-DRG, with a planned effective date of July 1, 2026, subject to approval of administrative rules and CMS. Provider revalidation continues, and providers will complete revalidation in the SD PECS enrollment system once it goes live.
South Dakota Medicaid · Effective May 15, 2026Medium impact
Physician Administered Drug Biosimilar PDL
South Dakota Medicaid is implementing a new Preferred Drug List (PDL) for physician-administered biosimilar drugs, requiring prior authorization for non-preferred agents with a 90-day trial of preferred drugs first. The policy rolls out in phases: tocilizumab (May 15, 2026), infliximab (June 15, 2026), and pegfilgrastim (July 15, 2026).
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.
UnitedHealthcare · Effective Feb 1, 2026Medium impact
AARP Medicare Supplement: Change to overpayment reimbursement process
AARP Medicare Supplement plans from UnitedHealthcare will automatically offset overpayments from future ACH electronic payments instead of sending letters requesting refunds. This streamlined process applies to providers receiving electronic payments through Optum Pay in 33 specified states.
South Dakota Medicaid · Effective Jan 1, 2026Medium impact
Esketamine Billing Instructions
South Dakota Medicaid is changing the HCPCS code for Esketamine (Spravato) nasal spray billing from S0013 to J0013 effective January 1, 2026. The policy clarifies specific E/M codes and add-on codes for associated professional services and observation time.
South Dakota Medicaid · Effective Jan 1, 2026Medium impact
Fall Provider Newsletter
South Dakota Medicaid is implementing major federal changes including work requirements for expanded Medicaid, reduced retroactive coverage periods, and more frequent eligibility checks. Hospital reimbursement methodologies will also be updated in 2026, and the Health Home program is being renamed to Care Connect.
South Dakota Medicaid · Effective Oct 1, 2025Medium impact
School Based Medicaid Program Updates
South Dakota Medicaid is updating its School-Based Medicaid program to comply with CMS regulations, including removal of non-sampled staff costs, updated RMTS requirements, new quarterly sampling periods, and mandatory annual Cost Settlement for schools submitting Direct Service claims. A new TM modifier will be required for services provided under 504 plans or other non-IEP/non-IFSP plans of care.
South Dakota Medicaid · Effective Jul 1, 2025Medium impact
Evaluation and Management Audio-Only Billing Updates
South Dakota Medicaid is replacing discontinued telephone consultation codes (98966-98968) with new audio-only E/M codes (98012-98015) for established patient visits. The new codes have specific time and medical decision-making requirements with updated reimbursement rates.
South Dakota Medicaid · Effective Jul 1, 2025Medium impact
Medicaid Reimbursement and Care Management Referral Updates
South Dakota Medicaid implemented a 1.25% rate increase for most services effective July 1, 2025, with targeted increases for specific transportation and physician codes. Additionally, care management referrals are no longer required for outpatient mental health services as of June 1, 2025.
South Dakota Medicaid · Effective Jun 1, 2025Medium impact
Summer Provider Newsletter
South Dakota Medicaid implemented multiple policy changes effective June 1 and July 1, 2025, including elimination of care management referrals for outpatient mental health services, inflationary rate increases up to 1.25% for services below target methodology, and expanded BabyReady program eligibility to 32 weeks gestation or less.
South Dakota Medicaid · Effective May 28, 2025Medium impact
Urgent Care Visit Billing Instructions
South Dakota Medicaid allows up to 4 urgent care visits per plan year (July 1 - June 30) without requiring referrals from care management providers. Specific billing instructions must be followed to ensure these visits are properly exempted from referral requirements.
HealthPartners · Identified Nov 6, 2026Medium impact
Fast Facts Newsletter - June (Special Edition) 2026
This June 2026 HealthPartners newsletter (issued 2026-06-01, first detected 2026-11-06, so historical material) lists coverage policy revisions, retirements and renames, plus reimbursement policy updates. Several changes are effective 08/01/2026 or 7/1/2026 (future relative to the source date but elapsed relative to the 2026-11-06 analysis date, so verify current applicability), while others were Reported as already effective in the historical source on 06/01/2026. Key items include a prosthesis policy adding prior authorization for protective outer surface covering systems (L5962, L5964), revised cardiac monitoring and cardiovascular risk screening criteria, endocrinology HbA1c criteria, a Minnesota wheelchair/robotic arm documentation update, a lumbar spinal fusion psychiatric evaluation timing change, and Cohere Health revisions for hip/knee arthroscopy, kyphoplasty/vertebroplasty and spinal cord stimulators.
South Dakota Medicaid · Identified Oct 16, 2026Medium impact
Medicaid Coverage of Ground
South Dakota Medicaid clarifies that ground ambulance providers may bill for medically necessary services provided at the pick-up point when an ambulance is dispatched but the patient is not transported. Providers must use HCPCS code A0429 (Emergent ground ambulance base fee, BLS) for these services; code A0998 is not recognized by South Dakota Medicaid and will not be reimbursed.
South Dakota Medicaid · Identified Oct 10, 2026Medium impact
Annual Hospital Cost Report Submission Reminder
South Dakota Medicaid is reminding in-state hospitals with a fiscal year ending June 30, 2026, that their annual Medicare Cost Report (CMS-2552-10) must be submitted to Provider Reimbursement & Audits by November 30, 2026. This is a submission deadline reminder for hospital cost reporting compliance.
South Dakota Medicaid · Identified Jun 21, 2026Medium impact
Immediate Family Members of the Household Providing Care
South Dakota Medicaid is extending the deadline by 6 months for Private Duty Nursing agencies to make alternative staffing arrangements when immediate family members can no longer provide paid caregiving services. The state is also exploring a waiver/exceptions process for extraordinary circumstances where no alternative care options exist.
South Dakota Medicaid · Identified Jun 21, 2026Medium impact
Care Connect Program
The Care Connect Program (formerly Health Home program) offers enhanced reimbursement and quality incentive payments to providers who enroll to provide care coordination services for Medicaid recipients with chronic conditions. This is a voluntary program that requires enrollment and coordination of comprehensive care including physical and behavioral health services.
South Dakota Medicaid · Identified Jun 21, 2026Medium impact
School District
South Dakota Medicaid issued updated billing reminders for school district and Birth to Three providers, emphasizing monthly eligibility verification, proper use of therapy assistant modifiers (HM, CO, CQ), and the TM modifier requirement for non-IEP/IFSP services that began October 1, 2025.
South Dakota Medicaid · Identified Jun 21, 2026Medium impact
Primary Care Provider Program
This policy update outlines the Primary Care Provider (PCP) program requirements for Medicaid providers, emphasizing comprehensive primary care services and 24/7 access to information. The policy also announces the upcoming Primary Accountable Care Transformation (PACT) initiative that will evolve Medicaid's primary care approach in 2026-2027.

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Summer Provider Newsletter

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)

HMS Disallowance and Recoupment Process

SFY27 Reimbursement

Breast Imaging - Medicare Advantage (Revised)

New DME process for select members in multiple states

CPT Code 92507 Billing Update Effective July 1 2025

Private Duty Nursing Members Providing Care

Claims Work Queue Inpatient Hospitals

Obstetrical Services Billing Changes

Hereditary cancer testing policy reminder

Credentialing transitioning to CertifyOS for some states

Neuroablative Techniques for Chronic Pain - Medicare Advantage (Revised)

08-28-2026 Coming soon: New provider enrollment and credentialing portal IM IE LA OC SAC SD

Noninvasive Tests for Hepatic Fibrosis - Medicare Advantage (Revised)

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

Medicaid Issues 9 Million

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

Liquid Biopsy - Medicare Advantage (Revised)

Fast Facts Newsletter - June (Special Edition) 2026

Coronary CT Angiography, Fractional Flow Reserve with CT and Adjunctive Testing - Medicare Advantage (Revised)

New DME process for select members in multiple states

Spring Provider Newsletter

Physician Administered Drug Biosimilar PDL

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

AARP Medicare Supplement: Change to overpayment reimbursement process

Esketamine Billing Instructions

Fall Provider Newsletter

School Based Medicaid Program Updates

Evaluation and Management Audio-Only Billing Updates

Medicaid Reimbursement and Care Management Referral Updates

Summer Provider Newsletter

Urgent Care Visit Billing Instructions

Fast Facts Newsletter - June (Special Edition) 2026

Medicaid Coverage of Ground

Annual Hospital Cost Report Submission Reminder

Immediate Family Members of the Household Providing Care

Care Connect Program

School District

Primary Care Provider Program