All Insurance Policy Changes (Page 17)

Continuing from page 16. 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
The New E-signing Process for Provider Enrollment Documents
BlueCross BlueShield of South Carolina·Effective Jun 9, 2025
BlueCross BlueShield of South Carolina launched an enhanced My Provider Enrollment Portal 2.0 on June 9, 2025, introducing electronic signature capability for provider enrollment documents. The billing team must understand the new e-signature workflow, critical email address entry requirements, and the 21-day deadline for completing signatures to avoid application cancellation and re-enrollment delays.
Medium impact
2025 August Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Aug 28, 2025
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released August 2025 medical policy updates affecting 48 policies. Most are annual reviews with no coverage intent changes but updated evidence, references, and rationale. Key changes include: two hematopoietic cell transplant policies archived; hepatitis testing expanded to immunosuppressed patients with new HCPCS code G0567; serum tumor markers coverage criteria broadened; familial hypercholesterolemia testing completely rewritten with new clinical suspicion definitions; and multiple genetic testing policies updated with new CPT codes and expanded repeat testing criteria.
High impact
2025 September Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Sep 26, 2025
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 45 medical policy updates effective September 2025, including 2 new policies (Dialectical Behavioral Therapy Programs CAM 395, Light Therapy for Seasonal Affective Disorder CAM 396), 1 major coverage expansion (Renal Denervation CAM 701136 now has positive coverage criteria), and important coding updates (13 new HCPCS codes added to Amniotic Membrane policy CAM 701149). Most updates are routine annual reviews with no coverage intent changes, but several require immediate attention for accurate billing and prior authorization workflows.
High impact
2025 October Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Oct 1, 2025
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released comprehensive October 2025 medical policy updates affecting 50+ policies, including three new spine surgery policies (CAM 401, CAM 400, CAM 399), addition of multiple new billing codes for genetic testing and diagnostic services effective 10/01/2025, and annual reviews with updated evidence/references for existing policies. Most changes involve CPT/HCPCS code additions and clarification updates with no change to coverage intent, but three new spine surgery policies require immediate review for coverage determination criteria.
High impact
Don't Forget Your 90-day Validations
BlueCross BlueShield of South Carolina·Identified Aug 11, 2026
South Carolina Blues requires all providers to validate their demographic data every 90 days to remain listed in provider directories. Providers who fail to validate within 90 days will be suppressed from directories until they complete validation through the M.D. Checkup portal in My Insurance Manager (MIM). This is a regulatory requirement under the Consolidated Appropriations Act (CAA) effective since January 1, 2022.
High impact
Important Updates for GLP-1 Provider Taxonomy Edits
BlueCross BlueShield of South Carolina·Effective Oct 1, 2025
Effective October 1, 2025, all GLP-1 diabetes medications (Trulicity, Byetta, Victoza, Ozempic, Rybelsus, Mounjaro) require prescribing providers to have an eligible taxonomy code reflecting diabetes management expertise. Claims will reject at the pharmacy if the provider's taxonomy does not match the approved list. Providers must verify and update their taxonomy codes immediately to avoid claim denials on commercial and Exchange plans.
High impact
Important Reminders for the E-sign Process for Provider Enrollment Applications
BlueCross BlueShield of South Carolina·Effective Jun 9, 2025
Blue Cross Blue Shield of South Carolina has updated the electronic signature (e-sign) process for provider enrollment applications effective June 9, 2025. Billing teams must ensure all required signer email addresses are accurately entered, monitor e-sign emails from specific BCBS addresses, and configure Adobe e-signatures to use 'Type' (not 'Image') to include required date/time stamps. Failure to comply will result in enrollment delays and returned applications for correction.
Medium impact
Introducing Coupe Health
BlueCross BlueShield of South Carolina·Effective Jan 1, 2026
BlueCross BlueShield of South Carolina is introducing Coupe Health, a new PPO plan option effective January 1, 2026, for self-insured employers. The key billing change is that Coupe members will not owe payment at time of service; instead, member liability is collected after final claim processing (non-finance model) or through a single monthly bill to Coupe (finance model). Claims are filed using standard BCBS processes, but eligibility checks will return 'no member payment due at time of service' messages.
High impact
2025 November Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Nov 1, 2025
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 33 medical policy updates and revisions effective November 2025. Key changes include: new psychological/neuropsychological testing policy (CAM 397), extended lumbar fusion revision surgery timeline (9-12 months vs 6-12 months), expanded HIV testing coverage with PrEP criteria, negative pressure wound therapy trial period extended from 14 to 30 days, multiple CPT code additions/removals in sexual health and infectious disease testing, and new minimal residual disease coverage for diffuse large B-cell lymphoma. Billing teams must immediately update claim submission rules, prior authorization triggers, and CPT code billing matrices across multiple service lines.
High impact
High Dollar Pre-payment Review Update for Group and Individual Plans
BlueCross BlueShield of South Carolina·Effective Jan 1, 2026
Effective January 1, 2026, BlueCross BlueShield of South Carolina lowers the High Dollar Pre-payment Review (HDPR) threshold from current levels to $75,000 or greater for inpatient institutional claims on Group and Individual plans. Hospitals must now submit itemized bills with detailed line-item descriptions, CPT/HCPCS codes, and revenue codes for pre-payment review when this threshold is met, except for per-diem, flat-fee, case rate, or DRG-based pricing. Claims will be adjusted to remove unbundled and nonreimbursable charges per the Inpatient Non-Reimbursable Charge/Unbundling Policy before payment.
High impact
New Year, Same 90-Day Validation Requirements
BlueCross BlueShield of South Carolina·Identified Aug 11, 2026
South Carolina Blues is reminding providers of the ongoing 90-day provider demographic validation requirement mandated by the Consolidated Appropriations Act (CAA). Providers must validate or update their demographic data every 90 days using M.D. Checkup in My Insurance Manager (MIM), or their locations will be suppressed from provider directories. Directory updates occur within two business days of successful validation.
High impact
2026 January Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Jan 1, 2026
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 35 updated medical policies effective January 2026, with the most critical changes being: (1) CPT code additions/deletions across multiple specialties effective 01/01/2026, (2) new investigational statements for Tibial Nerve Stimulation and Extracranial Carotid Artery Stenting, and (3) updated coverage denials for specific liver transplant indications. Most policies underwent annual reviews with no intent changes, but coding section updates require immediate billing system modifications.
Medium impact
Update to Pharmacy Benefit Drug Prior Authorization Process for Exchange Members
BlueCross BlueShield of South Carolina·Effective Apr 1, 2026
Beginning April 1, 2026, BlueCross BlueShield of South Carolina will internally manage non-specialty drug prior authorization requests for Exchange members, replacing OptumRx. This change affects Exchange plans with group numbers starting with 61, 62, or 65. Pharmacies and prescribers must submit PA requests through CoverMyMeds (ePA), phone, or fax using new contact information and updated forms.
High impact
Reminder: High Dollar Pre-payment Review Process
BlueCross BlueShield of South Carolina·Effective Mar 3, 2026
BlueCross BlueShield of South Carolina has activated a High Dollar Pre-payment Review (HDPR) process for inpatient institutional claims exceeding $100,000 (or $75,000 for Group/Individual plans). Hospitals must now submit detailed, itemized bills through My Insurance Manager for claims using discount-based pricing methodologies. This is a reminder of existing policy requirements, effective immediately.
High impact
Upcoming Post-payment Review Process Changes for Group and Individual Plans
BlueCross BlueShield of South Carolina·Identified Aug 11, 2026
BlueCross BlueShield of South Carolina will implement post-payment reviews of hospital claims through Cotiviti Inc. for group numbers 61, 62, 64, and 65. Affected claims include short-stay admissions, DRG-coded stays, and readmissions. Providers will have 45 days to respond to medical records requests, with a two-level appeal process available for disputed determinations.
High impact
New Phase Added to ClaimsXten
BlueCross BlueShield of South Carolina·Effective Mar 9, 2026
BlueCross BlueShield of South Carolina has activated Phase 3 of ClaimsXten (effective March 2026), adding three new auditing capabilities: outpatient consultation coding guidelines, duplicate claim submission detection, and unbundled code pair identification. Billing teams must immediately review and update internal coding practices to align with these enhanced edits to prevent claim denials and delays.
High impact
Updates on Lupron Depot Injections for State Health Plan Members
BlueCross BlueShield of South Carolina·Effective Jan 1, 2026
Effective January 1, 2026, Lupron Depot injections transitioned from pharmacy benefit coverage to medical benefit coverage for State Health Plan members. Prior authorization remains required and must now be submitted through MBMNow via My Insurance Insurance Manager℠. Billing team must route all Lupron Depot claims to the medical benefit and obtain prior authorization before administration.
Medium impact
Updated MOON Notice and Requirement for Medicare Advantage
BlueCross BlueShield of South Carolina·Effective Feb 24, 2026
CMS issued an updated Medicare Outpatient Observation Notice (MOON) on February 24, 2026, which BlueCross BlueShield of South Carolina now requires for all Medicare Advantage beneficiaries. The revised notice improves readability and design, is available in English and Spanish, and remains valid through February 28, 2029. Billing teams must ensure this notice is provided to patients receiving observation services to clarify they are outpatients, not inpatients.
High impact
Importance of Submitting Continued Stay Reviews in Cohere Health
BlueCross BlueShield of South Carolina·Effective Mar 25, 2026
South Carolina Blues has updated its Continued Stay Review (CSR) submission process in Cohere Health, requiring staff to select the 'start continuation' button BEFORE uploading clinical documentation. Failure to use this button prevents proper system flagging, delays responses, and can result in request rejection. This applies to inpatient hospitals, rehabilitation facilities, long-term acute care, and skilled nursing facilities with a 7-day submission deadline.
Medium impact
New Provider Coding Education Program, Provider Scope
BlueCross BlueShield of South Carolina·Effective Apr 3, 2026
BlueCross BlueShield of South Carolina is launching a new Provider Scope® Education program in partnership with Codoxo to monitor provider coding patterns using AI and rules-based analysis. Providers will receive education on billing practices and coding compliance, with potential for future prepay or post-pay audits if patterns are not addressed. No immediate operational changes are required, but providers should register for portal access to review their billing activity.
High impact
2026 April Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective Apr 1, 2026
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released April 2026 medical policy updates affecting multiple service lines. Key changes include: archiving 7 outdated policies, adding 6 new consolidated orthopedic arthroplasty/arthroscopy policies, removing investigational status for bioimpedance lymphedema devices, adding new meningococcal vaccine codes with updated benefit limits, and adding prosthetic code L2221. Most updates are annual reviews with no policy intent changes but updated evidence summaries.
High impact
Prior Authorization Transition from HealthHelp to Evolent — Effective July 1, 2026
BlueCross BlueShield of South Carolina·Effective Jul 1, 2026
Effective July 1, 2026, BlueCross BlueShield of South Carolina is transitioning prior authorization management for select cardiology and musculoskeletal (joint surgery) procedures from HealthHelp to Evolent for Exchange (ACA) plans with group numbers beginning 61, 62, or 65 (excluding Blue Direction plans). All PA requests for these services must now be submitted to Evolent via www.RadMD.com or phone 866-500-7664, and clinical documentation is required for all submissions.
High impact
2026 May Medical Policy Updates
BlueCross BlueShield of South Carolina·Effective May 29, 2026
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 40 medical policy updates effective May 29, 2026. Key billing changes include: (1) CPT codes 77062 and 77063 added for breast cancer screening; (2) HCPCS code S9943 replaces CPT codes 99401/99402 for breastfeeding counseling; (3) Seven new E-series codes (E0658, E0678-E0683) added for compression pumps; (4) CPT code 0423U added for pharmacogenetic testing; (5) One new policy (CAM 404) for Transcranial Magnetic Stimulation; (6) CAM 80133 expanded to include HDR temporary prostate brachytherapy as salvage therapy; (7) CAM 80160 reorganized criteria for ECMO; (8) CAM 90328 expanded to include epithelium-on corneal collagen products.
High impact
Notice to South Carolina Providers: Inpatient Readmission Payment Policy Updates
BlueCross BlueShield of South Carolina·Effective Aug 1, 2026
Effective August 1, 2026, BlueCross BlueShield of South Carolina will deny separate reimbursement for inpatient readmissions occurring within 30 days of a prior admission when the readmission is for a clinically related, potentially preventable diagnosis. Billing teams must implement medical review processes and documentation requirements to identify readmissions that qualify for this bundled payment policy. Certain admissions (behavioral health, transplants, maternity/newborn, and facility transfers) are exempt from this policy.
Medium impact
Updated Medicare Important Message (IM) and Detailed Notice of Discharge (DND) Forms
BlueCross BlueShield of South Carolina·Effective Jul 16, 2026
CMS has updated the Medicare Important Message (IM) and Detailed Notice of Discharge (DND) forms, effective immediately. Hospitals must use the new CMS-10065 form for all Medicare inpatient beneficiaries (both Original Medicare and Medicare Advantage) to inform them of discharge appeal rights. The previous forms may be used until May 15, 2026, but updated forms are required by that deadline.

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Insurance Policy Changes Tracker: All Payer Updates (Page 17) | PolicyChanges.app

The New E-signing Process for Provider Enrollment Documents

2025 August Medical Policy Updates

2025 September Medical Policy Updates

2025 October Medical Policy Updates

Don't Forget Your 90-day Validations

Important Updates for GLP-1 Provider Taxonomy Edits

Important Reminders for the E-sign Process for Provider Enrollment Applications

Introducing Coupe Health

2025 November Medical Policy Updates

High Dollar Pre-payment Review Update for Group and Individual Plans

New Year, Same 90-Day Validation Requirements

2026 January Medical Policy Updates

Update to Pharmacy Benefit Drug Prior Authorization Process for Exchange Members

Reminder: High Dollar Pre-payment Review Process

Upcoming Post-payment Review Process Changes for Group and Individual Plans

New Phase Added to ClaimsXten

Updates on Lupron Depot Injections for State Health Plan Members

Updated MOON Notice and Requirement for Medicare Advantage

Importance of Submitting Continued Stay Reviews in Cohere Health

New Provider Coding Education Program, Provider Scope

2026 April Medical Policy Updates

Prior Authorization Transition from HealthHelp to Evolent — Effective July 1, 2026

2026 May Medical Policy Updates

Notice to South Carolina Providers: Inpatient Readmission Payment Policy Updates

Updated Medicare Important Message (IM) and Detailed Notice of Discharge (DND) Forms