Consider Behavioral Health Evaluations During Hospital Stays

To help improve health outcomes for members receiving inpatient care, we encourage hospital staff and attending providers to consider behavioral health evaluations and follow‑up care coordination when appropriate.

Update: New Timeline on Updates to Payment Systems

We’re making changes to modernize payment processing and reduce paper check distribution.

New Claim Editing Rules To Be Implemented

On or after Dec. 1, 2026, we’ll update the Lyric software database to better align provider coding with industry standards. See what’s changing.

See Prior Authorization Changes for Some Commercial and Government Program Members

We’ve updated prior authorization requirements for some commercial non‑HMO members and government plans to reflect new, replaced or removed codes.

Discuss Flu Shots and Other Vaccines With Members

With flu season approaching, we encourage you to talk with our members about vaccines that can reduce the risk of illnesses and potentially serious outcomes.

Explore Learning Opportunities

We offer free webinars and workshops for providers who participate in our networks. View the schedule and sign up for training sessions, including a webinar on perinatal mental health.

MTM Health To Provide Medical Transportation for Medicaid Members

We’ll transition from Modivcare to MTM Health for nonemergency medical transportation for our members with Medicaid coverage, effective Oct. 1, 2026.

View PEAQ^SM Provider Performance Insights Reports

PPI reports for the Provider Efficiency, Appropriateness, & Quality^SM program are ready for eligible providers to access online.

Review Procedure Code and Fee Schedule Updates

On Sept. 1, 2026, we updated select codes in the 90635‑90756 and Q2034‑Q2039 Current Procedural Terminology (CPT^®) code ranges.

Verify Your Directory Information Every 90 Days

Our members and other providers rely on our provider directory for accurate information about your practice. Contracted providers’ directory data must be verified at least every 90 days, even if it hasn’t changed.

Take Note of Changes to Pharmacy Network for Some Commercial Members

On Aug. 3, 2026, we launched Pharmacy Match with Prime Therapeutics^®. This program expands the specialty pharmacy network and matches members who need specialty and complex care medications with qualified pharmacies.

See the Latest Pharmacy Prior Authorization Changes

We’re updating our standard pharmacy prior authorization programs. Changes affect members with prescription drug benefits administered by Prime. Review what’s changing as of Sept. 15, 2026.

Review Pharmacy Program Quarterly Updates – Part 1

We’ve made changes to our drug lists and utilization management program. Learn about these and other pharmacy program updates.

Learn About Updates to Reimbursement Policies

We regularly add and modify reimbursement policies, formerly known as clinical payment and coding policies, as part of our ongoing policy review. See which policies were updated.

Review Active and Pending Medical Policies

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.