All Insurance Policy Changes (Page 72)

Continuing from page 71. 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
Webinars for physicians, coders focus on documentation, coding
BCBS Michigan·Identified Jul 23, 2026
Blue Cross Blue Shield of Michigan is offering free educational webinars for physicians and coders throughout 2026 focusing on documentation and coding updates, including diabetes, oncology, ICD-10-CM, OB-GYN, and CPT changes. Previously recorded sessions on various coding topics are also available. This is an educational resource initiative with no billing code changes or coverage modifications.
Low impact
Reminder: Submit your questions for Q&A sessions that focus on unique prospective editing topics
BCBS Michigan·Identified Jul 23, 2026
Blue Cross Blue Shield of Michigan is inviting providers to submit questions for upcoming Q&A sessions focused on prospective editing topics. This is an informational notice about educational webinar opportunities, not a policy change affecting billing workflows or claims processing.
High impact
Reminder: Register for training about prior authorization changes for radiation oncology, therapeutic radiopharmaceuticals
BCBS Michigan·Effective Sep 1, 2026
Effective September 1, 2026, radiation oncology services (including proton beam therapy) and therapeutic radiopharmaceuticals will now be managed through the Oncology Value Management program administered by OncoHealth, requiring prior authorization through a new process. Providers must register for training webinars in August or September 2026 to understand the new requirements and workflow.
Medium impact
Learn more about prior authorization process for Human Organ Transplant program
BCBS Michigan·Effective Aug 1, 2026
Blue Cross Blue Shield of Michigan has published updated prior authorization procedures for their Human Organ Transplant program. The policy clarifies PA requirements for solid organ and bone marrow transplants for commercial members, while exempting cornea transplants, kidney transplants for self-funded groups, and skin transplants from prior authorization. A new detailed document on the Transplant Services page outlines steps for submitting outpatient PA requests, inpatient admission PAs, extensions, reauthorizations, and reconsideration reviews.
Medium impact
Do you have time for a Quality Minute about pharmacy measures?
BCBS Michigan·Effective Aug 1, 2026
Blue Cross Blue Shield of Michigan has added two new pharmacy performance measures (COB and Poly-ACH) to their Performance Recognition Program and Value-Based Reimbursements, effective August 2026. Additionally, a new exemption for Statin Use in Persons with Diabetes (SUPD) has been implemented, and a new 1health platform is available to help practices identify and improve medication adherence gaps for diabetes, hypertension, and cholesterol management.
Medium impact
Talk with patients now about Health Outcomes Survey topics
BCBS Michigan·Identified Jul 23, 2026
Blue Cross Blue Shield of Michigan is emphasizing that providers should proactively discuss Health Outcomes Survey (HOS) topics with Medicare Advantage patients during annual wellness visits. The policy focuses on four key areas: physical activity, bladder control, fall prevention, and mental health. This is an informational directive to align patient conversations with HOS questions that impact Star Ratings performance.
Medium impact
Use new addresses for paper claims for Blue Cross, BCN commercial members
BCBS Michigan·Effective Aug 1, 2026
Blue Cross Blue Shield of Michigan has consolidated and updated mailing addresses for paper claims submitted by Blue Cross commercial, BCN commercial, and BCN Advantage members. New addresses are active immediately, and the old P.O. boxes will no longer accept claims after September 30, 2026. The billing team must update all paper claim submission records to prevent claim rejections.
Medium impact
[California] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross Medicare Advantage in California is expanding its specialty pharmacy precertification requirements to include two new Medicare Part B drugs: Decnupaz (pivekimab sunirine-pvzy) and Lumvoa (veligrotug-vvze). Billing teams must implement prior authorization workflows for these drugs using the specified HCPCS and CPT codes to avoid claim denials.
Low impact
[California] You are invited: immunization measures webinar
Anthem BCBS·Identified Jul 23, 2026
Anthem Blue Cross is hosting an educational webinar on September 2, 2026 (12:00 PM ET / 4:00 PM UTC) covering HEDIS immunization measures, quality reporting, and vaccine hesitancy strategies. This is an invitation to a training event, not a policy change affecting billing, coverage, or coding.
Medium impact
[California] Continued collaboration on DRG clinical and coding validation
Anthem BCBS·Identified Jul 23, 2026
Anthem Blue Cross will continue conducting DRG clinical and coding validation audits through its Complex and Clinical Audit (CCA) team and external vendors (EXL and Ceris) for Medicare Advantage and Medi-Cal Managed Care plans in California. Providers should expect ongoing medical record requests and audit correspondence; the process remains consistent with efforts to minimize duplicate requests.
Medium impact
[New York] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage plans in New York are adding two specialty pharmacy medications (Decnupaz and Lumvoa) to their precertification review process. Billing teams must obtain prior authorization for these Medicare Part B drugs before claim submission to avoid denial.
Medium impact
[Ohio] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage in Ohio is expanding its specialty pharmacy precertification review process to include two additional Medicare Part B drugs: Decnupaz (pivekimab sunirine-pvzy) and Lumvoa (veligrotug-vvze). Billing teams must obtain precertification before administering these medications or claims will be rendered ineligible for reimbursement.
Medium impact
[Ohio] Continued collaboration on DRG clinical and coding validation
Anthem BCBS·Effective Jul 22, 2026
Anthem Blue Cross and Blue Shield Ohio Medicaid will continue conducting DRG clinical and coding validation audits through its Complex and Clinical Audit (CCA) team and designated external vendors (EXL and Ceris). Network providers may receive medical record requests and audit correspondence from Anthem and/or vendor partners. The review process remains consistent, with efforts to minimize duplicate requests.
Medium impact
[Virginia] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia are expanding their specialty pharmacy precertification requirements to include two new Medicare Part B drugs: Decnupaz (pivekimab sunirine-pvzy) and Lumvoa (veligrotug-vvze). Billing teams must implement prior authorization workflows for these medications or face claim denials.
Medium impact
[Virginia] Continued collaboration on DRG clinical and coding validation
Anthem BCBS·Effective Jul 22, 2026
HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid) will continue conducting DRG clinical and coding validation audits through its internal Complex and Clinical Audit team and designated external vendors (EXL and Ceris). Providers should expect to receive medical record requests from HealthKeepers and/or vendor partners as part of ongoing DRG validation activities, with efforts made to minimize duplicate requests.
Medium impact
[Georgia] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross Blue Shield (Medicare Advantage) in Georgia is expanding its specialty pharmacy precertification requirements to include two new Medicare Part B drugs: Decnupaz (pivekimab sunirine-pvzy) and Lumvoa (veligrotug-vvze). Billing teams must obtain precertification for these drugs before dispensing to avoid claim denials.
Medium impact
Annual Chlamydia Screening for PA CHIP Members Age 16+
Highmark·Effective Jul 22, 2026
Highmark PA CHIP now requires annual chlamydia screening for sexually active females ages 16+. This screening is covered at no cost as preventive care and is part of NCQA HEDIS performance metrics. Providers should implement annual screening protocols during well-child visits and use trauma-informed, patient-centered approaches when discussing sexual health.
Medium impact
Best Coding Practices: Migraines
Highmark·Effective Jul 22, 2026
Highmark has published updated best coding practices for migraine diagnosis and treatment, emphasizing the use of ICD-10 codes from category G43 to accurately characterize migraine type and reflect disease burden. Providers should reference the updated Coding Education resources on the Provider Resource Center for comprehensive coding guidance and video presentations.
High impact
Reminder: Annual Medicare Compliance Training
Highmark·Identified Jul 23, 2026
Highmark is reminding all Medicare providers and facilities that annual compliance training on fraud, waste, and abuse (FWA) is mandatory for all employees, contractors, volunteers, and governing-body members who work with Medicare Advantage and Part D members. Training must be completed within 90 days of hire and annually between January 1-December 31, with documentation maintained for the contract period plus 10 years.
Medium impact
Prevymis™ (letermovir) (Revised)
Humana·Effective Jul 22, 2026
This is a revised Prevymis (letermovir) prior authorization policy for Medicaid in Kentucky, South Carolina, and Virginia. The policy clarifies coverage for CMV prophylaxis in allogeneic hematopoietic stem cell transplant (HSCT) recipients (R+) and for CMV prophylaxis/treatment in solid organ transplant recipients who cannot tolerate valganciclovir. All requests require prior authorization with specific clinical criteria, age/weight requirements, and approval durations up to 12 months.
High impact
Simponi ARIA (golimumab) (Revised)
Humana·Effective Jan 1, 2019
This is a revised Simponi ARIA (golimumab) prior authorization policy for Medicaid in South Carolina, effective January 1, 2019, with the most recent revision dated July 22, 2026. The policy outlines specific clinical criteria and exclusions for coverage across four indications: ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. Key requirements include prior NSAID/DMARD therapy, age restrictions, contraindications to combination biologic therapy, and mandatory methotrexate co-therapy for rheumatoid arthritis unless contraindicated.
Medium impact
Topical Antifungals (Revised)
Humana·Effective Jan 1, 2020
This is a Step Therapy policy for topical antifungal medications (Exelderm, Luzu, Naftin, and sulconazole products) that requires members to have failed or be intolerant to two first-line topical antifungals (clotrimazole, ciclopirox, or ketoconazole) within the past 12 months before coverage is approved. The policy was revised on July 22, 2026, establishing the current authorization criteria for these medications.
Medium impact
Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (Revised)
Humana·Effective Sep 15, 2021
This is a revised Humana prior authorization policy for Rylaze (asparaginase Erwinia chrysanthemi recombinant-rywn) effective September 15, 2021, with a recent revision date of July 22, 2026. The policy requires prior authorization for Rylaze when used to treat ALL or Lymphoblastic Lymphoma in patients with Grade 2-4 hypersensitivity to prior Oncaspar treatment. The policy applies to Medicare, Medicaid in Kentucky, and Medicaid in South Carolina.
Low impact
Skyrizi® (risankizumab-rzaa) (Revised)
Humana·Effective Jul 22, 2026
Humana updated its Skyrizi (risankizumab-rzaa) prior authorization policy effective July 22, 2026. The policy maintains existing coverage criteria for four indications: plaque psoriasis (age 6+, with prior conventional oral systemic therapy requirement), psoriatic arthritis (age 6+), Crohn's disease (age 18+), and ulcerative colitis (age 18+). All approvals are granted in plan year durations or through clinical review. This is a routine policy revision with no substantive coverage changes from the previous version.
Medium impact
Xipere® (triamcinolone acetonide) (Revised)
Humana·Effective Jul 22, 2026
Humana's Xipere (triamcinolone acetonide) policy for Medicaid members in Kentucky and South Carolina was revised on July 22, 2026. This is a prior authorization requirement for the intraocular suspension used to treat macular edema associated with uveitis. The policy requires members to have a confirmed diagnosis of macular edema associated with uveitis to qualify for coverage.

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Archive by year

2023 2024 2025 2026

Webinars for physicians, coders focus on documentation, coding

Reminder: Submit your questions for Q&A sessions that focus on unique prospective editing topics

Reminder: Register for training about prior authorization changes for radiation oncology, therapeutic radiopharmaceuticals

Learn more about prior authorization process for Human Organ Transplant program

Do you have time for a Quality Minute about pharmacy measures?

Talk with patients now about Health Outcomes Survey topics

Use new addresses for paper claims for Blue Cross, BCN commercial members

[California] Expansion of the Specialty Pharmacy precertification list

[California] You are invited: immunization measures webinar

[California] Continued collaboration on DRG clinical and coding validation

[New York] Expansion of the Specialty Pharmacy precertification list

[Ohio] Expansion of the Specialty Pharmacy precertification list

[Ohio] Continued collaboration on DRG clinical and coding validation

[Virginia] Expansion of the Specialty Pharmacy precertification list

[Virginia] Continued collaboration on DRG clinical and coding validation

[Georgia] Expansion of the Specialty Pharmacy precertification list

Annual Chlamydia Screening for PA CHIP Members Age 16+

Best Coding Practices: Migraines

Reminder: Annual Medicare Compliance Training

Prevymis™ (letermovir) (Revised)

Simponi ARIA (golimumab) (Revised)

Topical Antifungals (Revised)

Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (Revised)

Skyrizi® (risankizumab-rzaa) (Revised)

Xipere® (triamcinolone acetonide) (Revised)