All Insurance Policy Changes (Page 148)

Continuing from page 147. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Updated Prior Authorization Expansion on Physician-administered Drugs
SC Medicaid - SCDHHS·Effective Jul 1, 2026
Effective July 1, 2026, South Carolina SCDHHS is expanding prior authorization requirements for physician-administered drugs covered under Healthy Connections Medicaid fee-for-service (FFS) plans. Billing teams must obtain prior authorization through Prime Therapeutics before administering the newly listed drugs to FFS Medicaid members, or claims will be denied.
High impact
Nonemergency Ambulance Transportation - MEDICAID - KENTUCKY (New)
Humana·Effective Jun 29, 2026
Humana Kentucky Medicaid has issued a new policy (effective 06/29/2026) establishing coverage criteria and prior authorization requirements for nonemergency ambulance transportation. Billing teams must now require prior authorization for nonemergency ground and air ambulance services (HCPCS codes A0428, A0430, A0431) and verify five specific medical necessity criteria before claim submission. This is a brand-new policy with no previous guidance superseded.
High impact
Multiplex Pathogen Identification Panels for Infectious Disease - MEDICAID - KENTUCKY (Revised)
Humana·Effective Jun 29, 2026
Humana Kentucky Medicaid revised its multiplex pathogen identification panel policy effective 06/29/2026, establishing new coverage criteria for infectious disease testing including respiratory panels, vaginal bacterial vaginosis tests, tropical fever panels, and cell-free DNA metagenomic sequencing. Prior authorization is now required for BD MAX Vaginal Panel (81514), Karius Test (0152U), and Bridge Women's Health Infectious Disease Detection Test (0330U). Several tests including NeXGen Fungal/AFB NGS (0531U), Johns Hopkins Metagenomic NGS (0323U), BIOTIA-ID Urine NGS (0590U), and Taq Array Card UTI Panel (0593U) are explicitly non-covered.
Low impact
06-22-2026 2026 Second Quarter Provider Newsletter IM IE LA OC SAC SD
Molina Healthcare·Effective Jun 22, 2026
Molina Healthcare of California has released its 2026 Second Quarter Provider Newsletter (effective June 22, 2026) covering multiple service counties. This is an informational bulletin directing providers to access the quarterly newsletter on Molina's website, which contains updates on medical management policies, utilization management, case management, formulary procedures, and clinical guidelines. The bulletin applies to Medi-Cal, Medicare, and Marketplace plans across seven California counties.
Medium impact
06-23-2026 Quick Guide for Providers Accessing Medi-Cal Member Redetermination Dates IE LA SAC SD
Molina Healthcare·Effective Jun 23, 2026
Molina Healthcare of California has released a new guide enabling providers to access Medi-Cal member redetermination (renewal) dates through three methods: Availity Essentials portal, monthly E-list membership files, and AVES eligibility verification system. Providers are now encouraged to proactively check member renewal dates and remind patients to complete annual eligibility reviews before their due dates to prevent coverage gaps.
High impact
Durable Medical Equipment and Orthotic and Prosthetic Manually Priced Procedure Codes - Prior Authorization Update
NC Medicaid - NCDHHS·Effective Apr 1, 2023
NC Medicaid beneficiaries disenrolling from Managed Care to NC Medicaid Direct will no longer have their prior authorizations for manually priced DME and O&P procedure codes automatically transferred. Providers must submit new prior authorization requests to NCTracks for these manually priced codes when a beneficiary transitions back to NC Medicaid Direct, effective April 1, 2023. Retroactive PA requests must be submitted within 90 days of the disenrollment notice.
Medium impact
Important information regarding Medicare GLP-1 Bridge through CMS
UPMC Health Plan·Effective Jul 1, 2026
CMS is launching the Medicare GLP-1 Bridge, a short-term demonstration program starting July 1, 2026, that provides GLP-1 medications to eligible Medicare Part D beneficiaries for weight management outside standard Part D coverage. The program uses a central processor for prior authorization, claims processing, and pharmacy payment. Billing teams must understand eligibility criteria and coordinate with this new pathway for GLP-1 claims.
High impact
Attention Psychiatric Residential Treatment Facility (PRTF) Providers: Prior Authorization Request Form Updated
Nevada Medicaid·Effective Jun 25, 2026
Nevada Medicaid has merged two prior authorization forms for Psychiatric Residential Treatment Facilities (PRTFs). The PRTF Concurrent Review form (FA-13) and PRTF Prior Authorization Request form (FA-15) are now combined into a single updated FA-15 form dated 06/25/2026. Providers must immediately discontinue use of the old forms and submit all PRTF prior authorization requests using only the new FA-15 form, or requests will be returned for resubmission.
Medium impact
Respiratory Syncytial Virus (RSV) Vaccine/Monoclonal Procedures Rate Update
Arkansas Medicaid·Identified Jun 26, 2026
Failed to analyze policy change
Low impact
R13842CP: Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – October 2026
Medicare/CMS - Transmittals·Identified Jun 26, 2026
This policy document provides contact information and resources for CMS Marketplace agents and brokers. However, there is a critical metadata error: the policy is titled 'R13842CP: Quarterly Update for DMEPOS Competitive Bidding Program – October 2026' but the actual content is unrelated agent/broker help desk information last updated May 2024. This appears to be a misfiled or incorrectly labeled document with no substantive billing policy changes for healthcare practices.
Medium impact
R13839OTN: Implementation of The Technical Consolidation of the Electronic Data Interchange(TCEDI) as the Production Translator for Inbound and Outbound X12 Transactions for Part A/BMACs
Medicare/CMS - Transmittals·Identified Jun 26, 2026
Failed to analyze policy change
Low impact
Members Sought for the Drug Utilization Review Board
Texas Medicaid·Identified Jun 26, 2026
This is a recruitment notice for the Texas Statewide Medicaid Drug Utilization Review Board, seeking qualified individuals to serve on the advisory board with terms expiring August 31, 2029. The application deadline is July 20, 2026, and board members must commit to quarterly meetings in Austin. This is administrative and informational in nature—it does not change billing procedures, coverage policies, or reimbursement rules for healthcare providers.
High impact
KMAP BULLETIN: Pharmaceutical Prior Authorization Updates – May 2026
Kansas Medicaid (KanCare)·Effective Jul 20, 2026
Effective July 20, 2026, KMAP (Kansas Medical Assistance Program) now requires Clinical Prior Authorization for 43 newly designated medications, including biologics, specialty pharmaceuticals, and rare disease treatments. Billing teams must implement prior authorization workflows for these drugs before the effective date to prevent claim denials for Kansas Medicaid beneficiaries.
Medium impact
AHCCCS Launches New Analytics Tool to Improve Claims Accuracy and Strengthen Program Integrity
Arizona Medicaid - AHCCCS·Effective Jun 25, 2026
AHCCCS is launching an advanced analytics tool (Alivia 360 platform) this summer to enhance pre-payment and post-payment claims review using AI and machine learning. The tool aims to identify billing pattern anomalies earlier, reduce payment delays, and improve claims accuracy while minimizing disruption for compliant providers. An additional enhancement release is planned for July 20, 2026.
Low impact
When disaster strikes, Regence is here to help you access the care you need
Regence BlueCross BlueShield of Oregon·Effective Jun 25, 2026
Regence has issued updated disaster/emergency response guidance for members in Idaho, Oregon, Utah, and Washington, clarifying coverage for out-of-network pharmacy refills during declared emergencies, emergency medical care at any hospital, and virtual care options. This is informational policy guidance for members rather than a billing or coverage rule change affecting claims processing or billing codes.
High impact
2026-06-25 - CY 2027 End-Stage Renal Disease Prospective Payment System Proposed Rule
Medicare/CMS·Effective Jan 1, 2027
CMS issued a proposed rule for CY 2027 updating ESRD dialysis payment rates, increasing the base rate to $299.55 (a 1.1% overall increase including $15.96 for phosphate binders), and modifying payment adjustments for low-volume facilities, pediatric patients, home/self-dialysis training, and transitional drug add-ons. Additionally, the newsletter covers multiple compliance items including PEPPER tool relaunch, Clinical Diagnostic Laboratory data reporting deadline (July 31, 2026), and corrected billing guidance for urinary catheters, tracheostomy supplies, and Hospital Outpatient PPS updates effective July 1, 2026.
High impact
MAB2026062501
Pennsylvania Medicaid (DHS)·Effective Jun 25, 2026
Pennsylvania Medical Assistance (Medicaid) has issued new prior authorization guidelines for upper extremity orthoses effective immediately (June 25, 2026). All prescriptions for upper extremity orthoses now require prior authorization with specific clinical documentation requirements based on orthosis type (shoulder, elbow, wrist-hand-finger, wrist-hand). Billing teams must ensure all UE orthosis claims include required medical necessity documentation before submission.
High impact
Important Update: One-Year Restriction on Federal Payments to “Prohibited Entities” Under H.R. 1 Section 71113 Ends Effective July 4, 2026
Medi-Cal·Effective Jul 4, 2026
Effective July 4, 2026, the one-year federal payment restriction on 'Prohibited Entities' under H.R. 1 Section 71113 expires, allowing these entities to resume submitting Medi-Cal and Family PACT claims for services rendered on or after that date. For the transition period (July 4, 2025–July 3, 2026), DHCS will not penalize providers for non-submission of claims or lack of associated documentation.
Low impact
Justice-Involved (JI) Reentry Initiative: Upcoming Live Training Webinars
Medi-Cal·Identified Jun 25, 2026
Medi-Cal is offering a series of live training webinars for providers participating in the Justice-Involved (JI) Reentry Initiative. These webinars cover JI screening portal usage, Medi-Cal claims overview, billing procedures for in-reach and embedded providers, and behavioral health service provider billing. Registration is required through the Medi-Cal Learning Portal (MLP) to attend.
Medium impact
Claims Reconciliation due to Vital Statistics System Updates
Maryland Medicaid·Identified Jun 25, 2026
Maryland Medicaid has identified system errors where participant date-of-death records in the vital statistics system caused unexpected claims denials. Maryland Medicaid is reviewing and reprocessing affected claims over the next few pay cycles. Providers impacted by these claim adjustments may file appeals or contact Maryland Medicaid for assistance.
Medium impact
Additional Extension of Temporary Moratoria for Certain Behavioral Health Providers for Certain Counties
Maryland Medicaid·Effective Jul 1, 2026
Maryland Medicaid is extending a temporary enrollment moratorium for four specific behavioral health provider types (PRP, PHP Level 2.5, IOP Level 2.1) for an additional six months in 10 Maryland counties, effective July 1, 2026. Providers in Anne Arundel, Baltimore City, Baltimore County, Carroll, Frederick, Harford, Howard, Montgomery, Prince George's, and Washington counties cannot submit new Medicaid enrollment applications for these services, though existing providers and individual practitioners are unaffected.
High impact
Incarceration Town Hall Presentation
Alaska Medicaid·Effective Dec 1, 2025
Alaska Medicaid updated its incarceration policy to comply with federal Section 5121 requirements (CAA 2023). Key changes: (1) Most Medicaid services suspend when members are incarcerated, except Division of Behavioral Health services and qualifying hospital stays (24+ hours); (2) Claims for incarcerated members now suspend for manual review instead of auto-denying, requiring providers to wait ~45 days post-discharge before submitting claims to avoid denials; (3) Justice-Involved Youth (ages up to 21, or up to 26 if former foster care) now receive Medicaid coverage for medical, dental, and behavioral health screenings 30 days before and 30 days after release, plus targeted case management.
Medium impact
Blue Advantage (HMO) Insight - October 2025
Blue Cross and Blue Shield of Louisiana·Effective Jan 1, 2026
Louisiana Blue released a provider newsletter with multiple October 2025 updates including new behavioral health authorization processes effective January 1, 2026, updated 2026 provider manuals, and revised medical policies. The most significant change is that Louisiana Blue will manage all behavioral health authorization and case management starting 2026, affecting workflow for behavioral health claims.
Low impact
Blue Advantage (HMO) Insight - March 2026
Blue Cross and Blue Shield of Louisiana·Identified Jun 25, 2026
Louisiana Blue has released a March 2026 provider newsletter containing multiple administrative updates including a new electronic provider disputes process, credentialing verification partner change to Medallion, updated medical policies, and CAHPS survey notifications. This is primarily an informational update with operational process changes rather than clinical billing impacts.
Low impact
Watch for Our Provider Availability and Access Survey
BCBS Oklahoma·Effective Jul 1, 2026
Blue Cross Blue Shield Oklahoma will conduct a provider availability and access survey from late July through early September 2026, contacting primary, specialty, and behavioral health providers via email and telephone. This survey supports NCQA accreditation and CMS guidelines; no billing workflow changes are required, but practices should prepare to respond when contacted.

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Archive by year

2023 2024 2025 2026

Updated Prior Authorization Expansion on Physician-administered Drugs

Nonemergency Ambulance Transportation - MEDICAID - KENTUCKY (New)

Multiplex Pathogen Identification Panels for Infectious Disease - MEDICAID - KENTUCKY (Revised)

06-22-2026 2026 Second Quarter Provider Newsletter IM IE LA OC SAC SD

06-23-2026 Quick Guide for Providers Accessing Medi-Cal Member Redetermination Dates IE LA SAC SD

Durable Medical Equipment and Orthotic and Prosthetic Manually Priced Procedure Codes - Prior Authorization Update

Important information regarding Medicare GLP-1 Bridge through CMS

Attention Psychiatric Residential Treatment Facility (PRTF) Providers: Prior Authorization Request Form Updated

Respiratory Syncytial Virus (RSV) Vaccine/Monoclonal Procedures Rate Update

R13842CP: Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) – October 2026

R13839OTN: Implementation of The Technical Consolidation of the Electronic Data Interchange(TCEDI) as the Production Translator for Inbound and Outbound X12 Transactions for Part A/BMACs

Members Sought for the Drug Utilization Review Board

KMAP BULLETIN: Pharmaceutical Prior Authorization Updates – May 2026

AHCCCS Launches New Analytics Tool to Improve Claims Accuracy and Strengthen Program Integrity

When disaster strikes, Regence is here to help you access the care you need

2026-06-25 - CY 2027 End-Stage Renal Disease Prospective Payment System Proposed Rule

MAB2026062501

Important Update: One-Year Restriction on Federal Payments to “Prohibited Entities” Under H.R. 1 Section 71113 Ends Effective July 4, 2026

Justice-Involved (JI) Reentry Initiative: Upcoming Live Training Webinars

Claims Reconciliation due to Vital Statistics System Updates

Additional Extension of Temporary Moratoria for Certain Behavioral Health Providers for Certain Counties

Incarceration Town Hall Presentation

Blue Advantage (HMO) Insight - October 2025

Blue Advantage (HMO) Insight - March 2026

Watch for Our Provider Availability and Access Survey