What insurance policy changes affect CPT 98961?

There are 10 tracked policy changes affecting CPT 98961, including updates from Anthem BCBS, Molina Healthcare, Nevada Medicaid. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 98961?

Payers that have issued tracked updates for CPT 98961 include: Anthem BCBS, Molina Healthcare, Nevada Medicaid, Harvard Pilgrim Health Care, New Mexico Medicaid, Florida Blue, Medi-Cal.

How do I get notified when CPT 98961 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 98961. You will receive a daily digest email whenever a new policy change references this code.

Why do payers change policies for CPT 98961?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

98961 Insurance Policy Changes

CPT 98961 is referenced in 10 tracked payer policy changes from Anthem BCBS, Molina Healthcare, and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 98961 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

High impact
[California] Medi-Cal Managed Care fee-for-service transition for members with unsatisfactory immigration status
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Medi-Cal Managed Care members with unsatisfactory immigration status (UIS) will transition to Medi-Cal fee-for-service (FFS) delivery. Providers must be enrolled in Medi-Cal FFS through PAVE by January 1, 2027, to continue serving these members and receive reimbursement. Billing workflows must shift from managed care to FFS processes, including Treatment Authorization Requests (TARs) and FFS-specific billing codes.
High impact
07-29-2026 DHCS policy guide for transition of the unsatisfactory immigration status population from managed care to Medi-Cal fee-for-service – Version 1.0 IE LA SAC SD
Molina Healthcare·Effective Jan 1, 2027
Effective January 1, 2027, Medi-Cal members with unsatisfactory immigration status (UIS) will transition from managed care plans to Medi-Cal Fee-for-Service (FFS). Providers must enroll in Medi-Cal FFS through DHCS to continue serving these patients and receive reimbursement. Billing workflows, care coordination processes, and prior authorization procedures will shift from managed care to FFS requirements.
High impact
Attention Provider Type 17 (Special Clinics) Specialty 181 (Federally Qualified Health Center): Shadow Billing Updates
Nevada Medicaid·Effective Jan 1, 2026
Nevada Medicaid updated shadow billing codes for Federally Qualified Health Centers (FQHCs) effective January 1, 2026. Key changes include: CPT codes 99205, 99242-99245, and H0049 now billable with both medical and behavioral health encounters; CPT 99401 with Modifier FP added with a 2-unit annual limit; and six codes (59514, 59612, 59620, 59812, 99401 with Modifier CR, G2214) are end-dated and no longer billable. Additionally, CPT codes 98960, 98961, and 98962 are restricted to medical encounters only.
High impact
Update: Telehealth flexibilities for Medicare members
Harvard Pilgrim Health Care·Effective Oct 1, 2025
Point32Health will continue telehealth coverage for Medicare Advantage members as supplemental benefits effective October 1, 2025, regardless of CMS decisions. Specific codes across multiple specialties including cardiac rehab, mental health, physical therapy, and pulmonary rehab will remain eligible for telehealth reimbursement.
Medium impact
Supplement 25-10: Implementation of Community Health Worker (CHW) and Community Health Representatives (CHR) Updates Per Repeal and Replace Letter of Direction
New Mexico Medicaid·Effective Aug 25, 2025
New Mexico Medicaid now covers Community Health Worker (CHW) and Community Health Representative (CHR) services starting August 25, 2025. CHWs/CHRs must enroll as Provider Type 462/Specialty 230, obtain DOH certification, and can bill CPT codes 98960-98962 for patient education services with physician orders or standing orders.
Medium impact
Attention Provider Type 17 (Special Clinics) Specialty 174 (Public Health Clinic): Update Regarding Claims for Education and Training
Nevada Medicaid·Effective May 19, 2025
Nevada Medicaid now allows Public Health Clinics (Provider Type 17, Specialty 174) to submit claims for patient education and training codes 98960-98962 without automatic suspension, effective May 19, 2025. Previously suspended claims dating back to June 2022 have been released for reprocessing.
Medium impact
Attention Provider Type 60 (School Health Services): Modifier GN is No Longer Required on Claims for Procedure Codes 98960, 98961, and 98962
Nevada Medicaid·Effective Apr 7, 2025
Nevada Medicaid has eliminated the requirement for modifier GN on CPT codes 98960, 98961, and 98962 when billed by School Health Services providers (type 60). This change allows non-speech language pathologists to bill these patient education codes without the outpatient speech language service modifier.
Medium impact
Attention Provider Type 89 (Community Healthcare Workers): Update to Error Codes for Service Limitations
Nevada Medicaid·Effective Feb 18, 2025
Nevada Medicaid updated error codes for Community Healthcare Workers (Provider Type 89) effective February 18, 2025. CHWs can now submit prior authorization requests to exceed daily and monthly service limits for patient education codes 98960-98962, with new PA override error codes replacing automatic denials.
Medium impact
Improve Behavioral Health Outcomes with Accurate Reporting
Florida Blue·Identified Jun 16, 2026
Florida Blue updated guidelines for behavioral health HEDIS reporting, emphasizing accurate documentation and coding for mental health and substance use disorder treatments. The policy highlights specific CPT codes 98960-98962 and HCPCS code G0155 for behavioral health screenings and follow-up visits to improve quality scores and patient outcomes.
Medium impact
Coming Soon: Important Policy Reminders and Clarifications for Covered Medi-Cal CHW Services
Medi-Cal·Identified May 3, 2026
California DHCS is updating the Medi-Cal Provider Manual to clarify billing requirements for Community Health Worker (CHW) preventive services, including individual and group billing procedures using specific CPT and HCPCS codes, and telehealth usage guidelines.

All billing codes J3590 99213 99212 99202 99214 99203

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[California] Medi-Cal Managed Care fee-for-service transition for members with unsatisfactory immigration status

07-29-2026 DHCS policy guide for transition of the unsatisfactory immigration status population from managed care to Medi-Cal fee-for-service – Version 1.0 IE LA SAC SD

Attention Provider Type 17 (Special Clinics) Specialty 181 (Federally Qualified Health Center): Shadow Billing Updates

Update: Telehealth flexibilities for Medicare members

Supplement 25-10: Implementation of Community Health Worker (CHW) and Community Health Representatives (CHR) Updates Per Repeal and Replace Letter of Direction

Attention Provider Type 17 (Special Clinics) Specialty 174 (Public Health Clinic): Update Regarding Claims for Education and Training

Attention Provider Type 60 (School Health Services): Modifier GN is No Longer Required on Claims for Procedure Codes 98960, 98961, and 98962

Attention Provider Type 89 (Community Healthcare Workers): Update to Error Codes for Service Limitations

Improve Behavioral Health Outcomes with Accurate Reporting

Coming Soon: Important Policy Reminders and Clarifications for Covered Medi-Cal CHW Services