- OIG/CMS flag underreported postoperative visits under global surgery — mandatory 99024 reporting applies to larger practices in 9 states.
- MetroPlusHealth waives PCP referral requirements for Gold Plan members, effective June 1.
- Fidelis Care launches its Apex 80 preventive-care incentive and rolls out new facility ED E/M overcoding review (Sept 1).
- EmblemHealth issues five claims-editing updates between June and November, plus reminders on cultural competency training, Medicaid consent documentation, wage parity filings, ownership disclosure, OMIG compliance, and provider-specific Medicaid certification anniversaries.
- Wellcare overhauls prior authorization — removing PA on a wide range of codes while adding it for wound care and medical transportation (Oct 1).
- Evolent adds cardiology/vascular codes to PA under Wellcare Medicare, effective January 1, 2027.
- Horizon previews the shift to component-based maternity billing, posts its network adequacy policy, flags EviCore imaging/radiation therapy guideline updates, and adjusts ferumoxytol reimbursement rules — among several other administrative changes.
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