Highlights

Key Updates

Policy Updates Prior AuthorizationCommercialMedicare AdvantageMedicaidJuly 1, 2025

Benefits of utilization management attestations: a guide for care providers

Education & TrainingMedicare AdvantageJune 17, 2025

2025 Medicare Advantage California EAE D‑SNP Fact Sheet

Policy Updates Medical Policy & Clinical GuidelinesMedicaidJune 16, 2025

Timely access to care course and standards

Quality ManagementMedicaidJune 5, 2025

Quality Incentive Program offerings for measurement year 2025


What's New

Recent Updates

Policy UpdatesMedicaidJuly 1, 2025

Clinical Criteria updates

Effective October 3, 2025

Policy Updates Prior AuthorizationCommercialMedicare AdvantageMedicaidJuly 1, 2025

Benefits of utilization management attestations: a guide for care providers

AdministrativeMedicare AdvantageJuly 1, 2025

Implementation of chargemaster‑based claims edit for ER leveling

AdministrativeMedicare AdvantageJuly 1, 2025

A quick guide to understanding JW and JZ modifiers

Administrative Digital SolutionsCommercialMedicare AdvantageMedicaidJuly 1, 2025

Seamless Provider Enrollment and Network Management through Availity Essentials optimizes the care provider experience

AdministrativeCommercialJuly 1, 2025

Enroll with Availity to verify your provider data

Education & TrainingCommercialJuly 1, 2025

Essential tips for accurate BlueCard claims

Education & TrainingCommercialJuly 1, 2025

Streamline BlueCard claims: Get the latest tips and best practices

AdministrativeCommercialMedicare AdvantageMedicaidJuly 1, 2025

Enhanced efficiency in dispute handling

Administrative Digital SolutionsCommercialMedicare AdvantageMedicaidJuly 1, 2025

Streamlining behavioral health authorizations via Availity Essentials

AdministrativeCommercialJuly 1, 2025

Benefits of being a Direct HMO provider

Education & TrainingMedicare AdvantageJuly 1, 2025

Combat diabetes: Close the statin therapy gap for better heart health

Education & Training WebinarsCommercialMedicare AdvantageMedicaidJuly 1, 2025

Join the 2025 Clinical Quality in Practice webinar series

Products & Programs PharmacyCommercialMedicare AdvantageMedicaidJuly 1, 2025

National Drug Codes (NDCs) are required for professional and outpatient claims

Education & TrainingMedicare AdvantageJune 27, 2025

Specialty pharmacy precertification list expanded

Education & TrainingMedicaidJune 26, 2025

Gender‑affirming care

AdministrativeCommercialJune 25, 2025

Self‑Insured Schools of California benefit reminder

Education & TrainingMedicare AdvantageJune 17, 2025

2025 Medicare Advantage California EAE D‑SNP Fact Sheet

Administrative Digital SolutionsMedicare AdvantageJune 17, 2025

Specialty pharmacy precertification list expansion — key updates

Policy Updates Medical Policy & Clinical GuidelinesMedicaidJune 16, 2025

Timely access to care course and standards

Products & Programs PharmacyMedicaidJune 10, 2025

Prior authorization updates for medications billed under the medical benefit

Quality ManagementMedicaidJune 5, 2025

Quality Incentive Program offerings for measurement year 2025

Policy UpdatesMedicare AdvantageJune 3, 2025

Clinical Criteria updates

Effective July 6, 2025

Products & Programs PharmacyCommercialMedicare AdvantageMedicaidJune 3, 2025

National Drug Codes (NDC) are required for outpatient claims

AdministrativeCommercialMedicare AdvantageJune 1, 2025

LabCorp and Quest Diagnostics are in-network — reminder

Products & Programs PharmacyCommercialJune 1, 2025

Unlock updated pharmacy insights today — visit our provider website

Education & TrainingMedicare AdvantageJune 1, 2025

Claims guidance: updating inpatient and outpatient bill types

Quality ManagementMedicaidJune 1, 2025

Enhance patient care with our Complex Case Management program

Education & Training WebinarsCommercialMedicare AdvantageMedicaidJune 1, 2025

Registration is now available for our upcoming CME webinar on Integrating Cancer Care

Quality ManagementMedicaidJune 1, 2025

Member rights and responsibilities for care providers

Administrative Digital SolutionsCommercialMedicare AdvantageMedicaidJune 1, 2025

Submitting BH authorizations in Availity Essentials

Education & TrainingMedicare AdvantageJune 1, 2025

Bridging the gap: enhancing medication adherence for better health outcomes

AdministrativeCommercialJune 1, 2025

Direct HMO: understanding the network design

Administrative Digital SolutionsMedicaidJune 1, 2025

Essential UM guidelines for timely service preapproval and reimbursement

Policy UpdatesMedicaidMay 28, 2025

Clinical Criteria updates

Effective August 29, 2025

Education & TrainingMedicare AdvantageMay 27, 2025

Learn about annual Model of Care training for special needs plans

Education & TrainingCommercialMedicare AdvantageMedicaidMay 27, 2025

Boost your roster submission skills with Availity Essentials

AdministrativeCommercialMay 22, 2025

Action required: annual patient safety attestation

Products & Programs PharmacyMedicare AdvantageMay 22, 2025

New specialty pharmacy medical step therapy requirements

Effective July 1, 2025
Pavblu, Ahzantive, Enzeevu, Opuviz, and Yesafili

Policy Updates Medical Policy & Clinical GuidelinesMedicaidMay 21, 2025

Medical Policies and Clinical Utilization Management Guidelines update

Effective August 24, 2025

Products & Programs PharmacyMedicaidMay 20, 2025

Prior authorization updates for medications billed under the medical benefit

Effective September 1, 2025
Tevimbra and Tyenne

Policy UpdatesMedicaidMay 14, 2025

Carelon Medical Benefits Management, Inc. updates

Effective August 15, 2025

Policy UpdatesMedicare AdvantageMay 13, 2025

Clinical Criteria updates

Effective June 20, 2025

AdministrativeCommercialMay 1, 2025

Annual grievance and appeals attestation requirement