All Insurance Policy Changes (Page 16)

Continuing from page 15. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Low impact
CME Webinar: Getting it Right from the Start: Identifying Patient Advanced Care Directives
UPMC Health Plan·Effective Oct 15, 2026
UPMC Health Plan is offering a CME-accredited webinar on October 15, 2026, to educate providers on identifying patient advance directives and surrogate decision makers during admission. This is an educational opportunity, not a billing or coverage policy change. The webinar aims to improve care coordination and reduce family conflict through early identification of decision-making authority.
Low impact
CME Webinar: Lifestyle Medicine in Practice: Evidence‑Based Strategies for Chronic Disease Care
UPMC Health Plan·Identified Aug 12, 2026
This is a CME educational webinar announcement on lifestyle medicine scheduled for September 23, 2026. It is not a billing policy change and does not affect coding, reimbursement, coverage, or billing workflows for the medical billing team.
Low impact
Preventive Care Connections - Community Resource Centers
L.A. Care Health Plan·Effective Aug 18, 2026
L.A. Care Health Plan is launching a new Community Resource Center (CRC) referral program to help patients access preventive care appointments, wellness services, and social support resources. This is a provider communication and care coordination initiative—not a billing code or reimbursement change. Billing teams should be aware this supports preventive care completion and may indirectly impact quality metrics and patient engagement tracking.
Low impact
Preventive Care Connections - Community Resource Centers
L.A. Care Health Plan·Effective Aug 18, 2026
L.A. Care Health Plan is promoting Community Resource Centers (CRCs) as a provider referral resource to help patients overcome barriers to preventive care (transportation, food insecurity, health education). This is an informational policy directing providers to refer eligible patients to local CRCs for wellness services, appointment scheduling assistance, and social support—not a billing or coding change.
Medium impact
Update: Viscosupplementation for Osteoarthritis Is a Covered Benefit for ERS Members
BCBS Texas·Effective Aug 11, 2026
Blue Cross Blue Shield of Texas has updated its policy to cover viscosupplementation injections for osteoarthritis treatment in ERS (Employees Retirement System of Texas) members across multiple joint sites (hip, knee, and other joints). The policy now includes coverage for both new viscosupplementation therapy initiation and continuation of maintenance injections for eligible members. Billing teams must verify coverage through Availity Essentials or vendor portals before rendering services.
Low impact
[Georgia] Influenza Testing - GA MCD-PY-1543 - Retired & Archival
CareSource·Effective Sep 10, 2026
Effective September 10, 2026, Georgia Medicaid is retiring the Influenza Testing Policy (GA MCD-PY-1543) and archiving it. Going forward, all influenza testing claims must be billed according to CMS and NCCI guidelines rather than the retired state-specific policy. No new billing codes or requirements are introduced; providers should continue following standard coding guidelines.
High impact
BT2026133: IHCP reminds dental providers of the appropriate claim filing code
Indiana Medicaid (IHCP)·Effective Aug 11, 2026
IHCP clarifies that dental providers must use claim filing code CI (Commercial Insurance Co.) for all dental claims submitted for fee-for-service Medicaid members with Medicare Advantage Plans as primary coverage. Previously, some providers incorrectly used MA and MB codes, resulting in overpayments. Since dental services are excluded from Medicare Parts A and B, Medicare Advantage dental coverage is treated as commercial insurance.
Medium impact
COVID At-Home Rapid Antigen Test Kit Quantity Limit
Illinois Medicaid - HFS·Effective Sep 1, 2026
Effective September 1, 2026, Medicaid will limit COVID At-Home Rapid Antigen Test Kits to 8 units per beneficiary per rolling 365-day calendar year across both Fee-for-Service (FFS) and Managed Care Organization (MCO) plans. Billing teams must implement quantity controls in their systems to enforce this new annual limit and prevent claim denials for excess quantities.
High impact
26-933 DHCS Confirms Expiration of the Temporary Federal Payment Restriction Under H.R. 1
Health Net·Effective Jul 4, 2026
As of July 4, 2026, the temporary federal payment restriction for certain Medi-Cal providers classified as prohibited entities under H.R. 1 has expired. Affected providers may now resume submitting claims for covered Medi-Cal services with dates of service on or after July 4, 2026, and claims will be processed through standard adjudication procedures. This supersedes previous guidance from provider update 25-1073.
High impact
26-934 DHCS Confirms Expiration of the Temporary Federal Payment Restriction Under H.R. 1
Health Net·Effective Jul 4, 2026
A one-year federal payment restriction on certain Medi-Cal providers classified as prohibited entities under H.R. 1 has expired as of July 4, 2026. Affected providers may now resume submitting claims and encounters for covered Medi-Cal services with dates of service on or after July 4, 2026, and claims will be processed through standard adjudication procedures. This supersedes previous guidance from provider update 25-1074.
High impact
26-999 ECM Billing Limits Take Effect October 15, 2026
Health Net·Effective Oct 15, 2026
Beginning October 15, 2026, Enhanced Care Management (ECM) claims are subject to a new monthly billing limit of 10 units per member, per calendar month. Claims exceeding this limit will be denied. The billing team must implement controls to ensure accurate unit reporting (1 unit = 1 hour), apply Medicare rounding rules, and maintain detailed documentation to support all billed services and appeals.
High impact
26-1000 ECM Billing Limits Take Effect October 15, 2026
Health Net·Effective Oct 15, 2026
Effective October 15, 2026, Enhanced Care Management (ECM) claims are subject to a new monthly billing limit of 10 units per member per calendar month. Claims exceeding this limit will be denied. The policy clarifies that 1 unit equals 1 hour of covered ECM service, specifies which activities are billable versus non-billable, and requires providers to maintain detailed documentation to support appeals of denied claims.
High impact
26-1001 ECM Billing Limits Take Effect October 15, 2026
Health Net·Effective Oct 15, 2026
Effective October 15, 2026, Enhanced Care Management (ECM) claims are subject to a new monthly billing limit of 10 units per member per calendar month. Claims exceeding this limit will be denied. Prior authorization is not required, but billing teams must ensure accurate unit reporting (1 unit = 1 hour), maintain supporting documentation, and understand which ECM activities are covered versus non-billable.
High impact
26-935 DHCS Confirms Expiration of the Temporary Federal Payment Restriction Under H.R. 1
Health Net·Effective Jul 4, 2026
Effective July 4, 2026, the one-year federal payment restriction on certain Medi-Cal providers classified as prohibited entities under H.R. 1 has expired. Affected providers may now resume submitting claims and encounters for covered Medi-Cal services with dates of service on or after July 4, 2026, and claims will be processed through standard adjudication procedures. This supersedes previous guidance from provider update 25-1075.
Medium impact
26-1019 State of Emergency: Gann Fire in Calaveras County
Health Net·Effective Aug 6, 2026
Health Net is temporarily suspending prior authorization, precertification, and referral requirements for Calaveras County members affected by the Gann Fire (declared state of emergency August 6, 2026). Billing teams must adjust workflows to allow expedited approvals, extended authorization validity periods, out-of-network service coverage, prescription refill flexibility, and extended claims filing deadlines for impacted providers and members in this county.
High impact
All Provider Bulletin 419: Transition to Separate Reporting of Maternity Care Services
MassHealth·Effective Sep 1, 2026
Effective September 1, 2026, MassHealth requires providers to transition maternity care billing for new patients to evaluation and management (E/M) codes with TH modifier instead of global maternity CPT codes (59425, 59426, etc.). Existing patients with first prenatal visits before September 1, 2026 continue using legacy codes; new patients after that date must use appropriate E/M codes (99202-99205 for new patients, 99211-99215 for established patients, plus telemedicine codes) based on medical decision-making level.
Medium impact
Immersive Virtual Reality Therapy for Chronic Lower Back Pain
Blue Cross & Blue Shield of Mississippi·Effective Aug 1, 2026
Blue Cross Blue Shield has added a new policy (A.3.03.06) classifying FDA-authorized prescription virtual reality therapeutics for chronic lower back pain as investigational. RelieVRx is currently the only FDA-cleared product in this category. Billing teams must recognize CPT 40770T as an investigational code and ensure proper prior authorization and medical necessity documentation before claims submission.
Medium impact
Audio-Visual Neuromodulation for Neuropathic Pain
Blue Cross & Blue Shield of Mississippi·Effective Aug 1, 2026
New policy effective August 1, 2026, classifies all FDA-authorized prescription audiovisual digital therapeutics for neuropathic pain (currently only the Sana Device) as investigational and non-covered. Billing teams must deny claims for this technology and communicate non-coverage status to patients and providers immediately.
High impact
Reminder: Importance of Correct Coding
BlueCross BlueShield of South Carolina·Effective Jan 27, 2025
South Carolina Blues issued a reminder on coding best practices to ensure accurate claim submission and timely processing. The policy highlights seven common coding errors—invalid modifiers, incorrect units, code inconsistencies, bundling violations, age mismatches, unspecified codes, and procedure-diagnosis misalignment—and requires billing teams to verify accuracy before claim submission to minimize denials.
Low impact
Have You Checked our Medical Policies?
BlueCross BlueShield of South Carolina·Effective Jan 31, 2025
BlueCross BlueShield of South Carolina issued a reminder (dated Jan. 31, 2025) clarifying that their medical policies are evidence-based guidance, not guarantees of payment, and that actual coverage depends on individual member benefit plans. Providers should verify specific coverage details through Provider Services rather than relying solely on policy codes, as each health plan applies policies differently.
Medium impact
Reminder: BlueExtend Plan
BlueCross BlueShield of South Carolina·Effective Feb 7, 2025
BlueCross BlueShield of South Carolina clarifies that BlueExtend plan members must use BlueEssentials network providers while in South Carolina and can access BlueCard Program (PPO) only when traveling outside the state. This is a coverage network restriction reminder for an ACA-compliant plan offered in select South Carolina counties.
High impact
2025 February Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Feb 27, 2025
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released February 2025 medical policy updates affecting 50+ policies. Most changes involve routine updates to rationale and references with no change to coverage intent, but three policies contain material changes: (1) Bariatric Surgery (CAM 70147) now states routine esophagogastroduodenoscopy is investigational and not medically necessary; (2) Testing for Developmental Delay (CAM 259) significantly restricts coverage to only chromosomal microarray, whole exome sequencing, whole genome sequencing, fragile X syndrome testing, or Rett syndrome testing; and (3) Multiple new billing codes added effective 04/01/2025 for genetic and pathology testing.
High impact
2025 April Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Apr 25, 2025
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan issued 24 medical policy updates effective April 25, 2025, including critical coverage changes: telehealth reimbursement elimination for PT/OT/SLP services, new coverage for laser thermal therapy for epilepsy/brain tumors, denial of cosmetic lipectomy procedures, and addition of new diagnostic codes (colorectal screening, H. pylori testing, coronary artery imaging). Most updates are administrative clarifications, but several directly impact claim submission and reimbursement decisions.
High impact
Reminder: GLP-1 Utilization Management
BlueCross BlueShield of South Carolina·Effective Sep 1, 2025
Effective September 1, 2025, all GLP-1 medications require prior authorization and must be prescribed only for FDA-approved indications by authorized providers with diabetes management expertise. GLP-1 agents prescribed for non-FDA-approved uses or by unauthorized providers will be denied. Additionally, Zepbound and Wegovy will not be covered under plans that exclude weight loss medications, regardless of the specific diagnosis (sleep apnea or cardiovascular disease), due to drug classification-based coverage determinations.
Medium impact
2025 July Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Jul 29, 2025
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released their July 2025 medical policy updates, which include mostly routine annual reviews with no changes to policy intent. However, three policies have actionable coding updates: CAM 701136 adds code C1735 (effective 01/01/2025), CAM 701149 adds 12 new amniotic membrane codes (effective immediately), and CAM 20219 updates code 93656 verbiage (effective 07/01/2025). Additionally, CAM 089 updates ICD-10 code Z1331 for anxiety/depression screening. Most other policies reflect evidence and reference updates only.

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Archive by year

2023 2024 2025 2026

CME Webinar: Getting it Right from the Start: Identifying Patient Advanced Care Directives

CME Webinar: Lifestyle Medicine in Practice: Evidence‑Based Strategies for Chronic Disease Care

Preventive Care Connections - Community Resource Centers

Preventive Care Connections - Community Resource Centers

Update: Viscosupplementation for Osteoarthritis Is a Covered Benefit for ERS Members

[Georgia] Influenza Testing - GA MCD-PY-1543 - Retired & Archival

BT2026133: IHCP reminds dental providers of the appropriate claim filing code

COVID At-Home Rapid Antigen Test Kit Quantity Limit

26-933 DHCS Confirms Expiration of the Temporary Federal Payment Restriction Under H.R. 1

26-934 DHCS Confirms Expiration of the Temporary Federal Payment Restriction Under H.R. 1

26-999 ECM Billing Limits Take Effect October 15, 2026

26-1000 ECM Billing Limits Take Effect October 15, 2026

26-1001 ECM Billing Limits Take Effect October 15, 2026

26-935 DHCS Confirms Expiration of the Temporary Federal Payment Restriction Under H.R. 1

26-1019 State of Emergency: Gann Fire in Calaveras County

All Provider Bulletin 419: Transition to Separate Reporting of Maternity Care Services

Immersive Virtual Reality Therapy for Chronic Lower Back Pain

Audio-Visual Neuromodulation for Neuropathic Pain

Reminder: Importance of Correct Coding

Have You Checked our Medical Policies?

Reminder: BlueExtend Plan

2025 February Medical Policy Updates

2025 April Medical Policy Updates

Reminder: GLP-1 Utilization Management

2025 July Medical Policy Updates