Insurance Updates

10 Key Things You Need to Know

• Skin Substitutes Reimbursement Overhaul (Effective Jan 1, 2026): Horizon aligns with CMS 2026 PFS Final Rule — skin substitute products now paid as incident-to supplies (not biologicals) for application procedures in non-facility (PFS) or hospital outpatient (OPPS) settings. Categories align with FDA status (361 HCT/Ps, PMA devices, 510(k) devices). All use a single flat rate (based on highest average ASP from Oct 2024 data) to recognize differences, support innovation, and cut Medicare waste — Horizon updates its fee schedule accordingly for commercial, Braven Health, ASO (incl. SHBP/SEHBP) plans.
• NJ DIRECT Lab Testing Requirement (Effective April 20, 2026): For NJ DIRECT (SHBP/SEHBP) members, submit lab samples only to preferred partners LabCorp or Quest Diagnostics — claims for most lab services will deny if not sent there (no member liability for denials). Exceptions for certain in-office procedures (see Horizon’s Eligible Lab Procedures webpage); hospital-collected specimens follow hospital rules. Check member ID card or Availity Eligibility tool to identify NJ DIRECT patients.
• Prior Authorization Relief — ~300 Codes Removed (Effective Jan 26, 2026): Horizon eliminates prior auth requirements for nearly 300 service codes across Horizon, Horizon NJ TotalCare (HMO D-SNP), and Braven Health plans — no PA needed for services on/after this date. Aims to reduce admin burden, let providers focus on care. Use Prior Authorization Procedure Search Tool or Availity Utilization Management Request Tool (updates reflect changes Jan 26).
• EviCore Clinical Guideline Updates (Effective March 30, 2026): Multiple imaging guidelines revised (e.g., Abdomen, Breast, Cardiac, Oncology, Spine, Musculoskeletal, Pediatric variants, PNND/PVD). Changes may impact PA/medical necessity determinations for Horizon NJ Health Radiology/Cardiology programs. Review via EviCore Provider Hub → Cardiovascular & Radiology → search “Horizon Medicaid” → Future tab.
• Braven Health Referral & Benefits Guidance: Refer Braven Health (Medicare Advantage) patients to in-network providers for max coverage, lower OOP costs, better care coordination. Use Doctor & Hospital Finder. Vision via Davis Vision (call 1-888-257-1267); Hearing via HearUSA (call 1-855-825-4706). Out-of-network = higher costs; complex eye/hearing issues to in-network specialists.
• Radiology/Cardiology/Ultrasound Code Bundling Changes: Effective Feb 11, 2026 — new reimbursement formula for codes 72197 + 72198 + 73725 (100% of 73725, 50% of 72198, 0% of 72197; reverses prior logic). Effective Jan 1, 2026 — several code bundling combos deleted (esp. obstetric/fetal/vascular ultrasounds in 76801–76828 range) and numerous code pairs removed from Correct Coding Rules Bank (e.g., adrenal/venous imaging, fluoroscopy guidance, endovascular repairs, CT perfusion combos) — all per CMS edits, managed via EviCore.
• Injectable/Specialty Drug Reimbursement Cuts (Effective May 1, 2026): Major downward adjustments to HCPCS rates for many drugs (payer-driven, not standard ASP/AWP updates). Hits hard in oncology/immuno-oncology (e.g., pembrolizumab J9271, rituximab J9312, trastuzumab J9355), IVIG products, hematology/growth factors, rare disease biologics, wound care Q-codes (many now AWP-15%), and biosimilars. Lower buy-and-bill margins expected; check via Availity Fee Schedule Inquiry Tool. Horizon may retro-adjust claims.
• Horizon NJ Health Provider Resources Reminder: Access key materials via Horizon NJ Health site — clinical guidelines, forms, formulary, Pulse newsletter, member rights, Provider Manual, cultural competency training (via HHS Think Cultural Health), UM info, Availity portal. Contact Provider Services (1-800-682-9091) or Account Specialist for support/printed materials.
• Fidelis Care Group/Family Therapy Authorization Update: For 90847 (family) & 90853 (group) — first 26 (or 30 in some notices) visits/calendar year: no auth needed. Beyond that: concurrent review/notification required (submit form + treatment plan, first DOS, verification of initial visits). Excludes SUD services under Article 32 licensed providers. Applies to dates exceeding threshold from Jan 1, 2025/2026 onward.
• Upcoming Notable New Drugs (Optum Rx Winter 2026 Report): Watch for potential Q1 2026 FDA approvals: Anaphylm (dibutepinephrine) — first oral (sublingual film) emergency anaphylaxis treatment (needle-free, portable, ~$710/2 doses). Sotyktu (deucravacitinib) expansion to psoriatic arthritis (oral TYK2 inhibitor, safer profile vs. some JAKs). Insulin icodec — first once-weekly basal insulin for type 2 diabetes (convenience advantage, but potential hypo risk & higher cost vs. daily options like Lantus).