All Insurance Policy Changes (Page 150)

Continuing from page 149. 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
Reminder: Expansion of vendor program and training sessions
Harvard Pilgrim Health Care·Effective Oct 1, 2025
Effective October 1, 2025, Evolent will assume utilization management (prior authorization) for spine and interventional pain management services for Tufts Medicare Preferred members. Prior authorization requirements are changing for specific CPT codes—some codes will have authorization requirements removed, others newly require authorization, and some will continue through Evolent instead of Tufts Health Plan. Billing teams must update systems to route authorization requests to Evolent and track code-specific authorization requirements.
High impact
New laboratory Payment Policies
Harvard Pilgrim Health Care·Effective Nov 1, 2025
Harvard Pilgrim Health Care is implementing a new laboratory benefit management program with automated claims edits for 60+ specific lab tests and procedures effective November 1, 2025. These evidence-based policies will apply to office, hospital outpatient, and independent laboratory settings (excluding ER, observation, and inpatient). Billing teams must review detailed payment policies on the provider website and adjust ordering/requisition forms to ensure compliance and avoid claim denials.
High impact
Update on medical record review programs
Harvard Pilgrim Health Care·Effective Nov 1, 2025
Point32Health is transitioning medical record review programs for Tufts Health Plan products to Optum, effective November 1, 2025. Providers will receive requests from Optum for medical records and billing documents to verify accurate coding, documentation, and compliance. Documentation must include provider orders supporting all charges and clinical documentation supporting diagnoses and billed services.
High impact
Update on coverage of weight loss medication
Harvard Pilgrim Health Care·Effective Jan 1, 2026
Effective January 1, 2026, Harvard Pilgrim Health Care Commercial and Tufts Health Direct plans are significantly restricting coverage of weight loss medications, including GLP-1 drugs for weight loss and alternative indications (cardiovascular, comorbidities). Most formularies (Core, Select, ConnectorCare) will exclude coverage entirely, while plans retaining coverage must require new GLP-1 users to complete a 6-month behavior modification program before accessing Zepbound. All existing prior authorizations for weight loss medications will terminate with no grandfathering.
Medium impact
Point32Health Payment Policy updates
Harvard Pilgrim Health Care·Effective Oct 1, 2025
Point32Health has updated 11 payment policies effective October 1, 2025, affecting Harvard Pilgrim Health Care and Tufts Health Plan products. Most changes are minor administrative edits for clarity, but three policies require attention: Transplants (consolidates two separate policies into one integrated policy), Applied Behavioral Analysis Services (renamed from Autism Services with updated medical necessity guidelines), and Inpatient/Intermediate Behavioral Health (adds billing instructions for Administratively Necessary Days).
Medium impact
Point32Health Medical Necessity Guideline updates
Harvard Pilgrim Health Care·Identified Jun 26, 2026
Failed to analyze policy change
Medium impact
June-July 2026 Provider Payment Schedule and Provider Service Center Holiday Hours
SC Medicaid - SCDHHS·Effective Jun 12, 2026
The South Carolina Department of Health and Human Services has implemented temporary payment schedule changes for Healthy Connections Medicaid in June-July 2026 due to federal holidays. Claims submitted by June 12, 2026, will have payments dated June 19, 2026, but ACH files delayed until June 22, 2026. The July 3, 2026 payment cycle is moved up with a June 26, 2026 submission deadline. Provider Service Center will be closed July 3, 2026.
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.

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Archive by year

2023 2024 2025 2026

Reminder: Expansion of vendor program and training sessions

New laboratory Payment Policies

Update on medical record review programs

Update on coverage of weight loss medication

Point32Health Payment Policy updates

Point32Health Medical Necessity Guideline updates

June-July 2026 Provider Payment Schedule and Provider Service Center Holiday Hours

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