Highlights

Key Updates

Policy Updates Prior AuthorizationCommercialMedicare AdvantageJuly 1, 2025

Benefits of utilization management attestations: a guide for care providers


What's New

Recent Updates

Policy Updates Prior AuthorizationCommercialMedicare AdvantageJuly 1, 2025

Benefits of utilization management attestations: a guide for care providers

Policy Updates Reimbursement PoliciesCommercialJuly 1, 2025

Material adverse change

New reimbursement policy: Code and Clinical Editing Guidelines – Professional and Facility

Policy Updates Reimbursement PoliciesCommercialJuly 1, 2025

Material adverse change

Reimbursement policy update: Bundled Services and Supplies – Professional

AdministrativeMedicare AdvantageJuly 1, 2025

Implementation of chargemaster‑based claims edit for ER leveling

AdministrativeCommercialJuly 1, 2025

A quick guide to understanding JW and JZ modifiers

AdministrativeMedicare AdvantageJuly 1, 2025

A quick guide to understanding JW and JZ modifiers

Administrative Digital SolutionsCommercialMedicare AdvantageJuly 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

Policy Updates Prior AuthorizationCommercialJuly 1, 2025

Material adverse change

Precertification/prior authorization list change notification July 1, 2025

Policy UpdatesCommercialJuly 1, 2025

Material adverse change

Clinical UM Guidelines updates

Policy UpdatesCommercialJuly 1, 2025

Readmission review process change

AdministrativeCommercialJuly 1, 2025

CMS drug fee schedule update effective August 1, 2025

Administrative Digital SolutionsCommercialMedicare AdvantageJuly 1, 2025

Streamlining behavioral health authorizations via Availity Essentials

Policy Updates Reimbursement PoliciesCommercialJuly 1, 2025

Reimbursement policy update: Nurse Practitioner and Physician Assistant services

Education & TrainingMedicare AdvantageJuly 1, 2025

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

Education & Training WebinarsCommercialMedicare AdvantageJuly 1, 2025

Join the 2025 Clinical Quality in Practice webinar series

Products & Programs PharmacyCommercialMedicare AdvantageJuly 1, 2025

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

Education & TrainingMedicare AdvantageJune 27, 2025

Specialty pharmacy precertification list expanded

Administrative Digital SolutionsMedicare AdvantageJune 17, 2025

Specialty pharmacy precertification list expansion — key updates

Products & Programs PharmacyCommercialMedicare AdvantageJune 6, 2025

National Drug Codes (NDCs) are required for outpatient claims

Policy UpdatesMedicare AdvantageJune 2, 2025

Clinical Criteria updates

Effective July 6, 2025

AdministrativeCommercialMedicare AdvantageJune 1, 2025

LabCorp and Quest Diagnostics are in-network — reminder

Products & Programs PharmacyCommercialJune 1, 2025

Material adverse change

Drug list updates — designated medical specialty pharmacy

Products & Programs PharmacyCommercialJune 1, 2025

Unlock updated pharmacy insights today — visit our provider website

Education & TrainingCommercialJune 1, 2025

Availity Essentials Provider Overpayments application launch

Education & TrainingMedicare AdvantageJune 1, 2025

Claims guidance: updating inpatient and outpatient bill types

Education & Training WebinarsCommercialMedicare AdvantageJune 1, 2025

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

Education & TrainingMedicare AdvantageJune 1, 2025

Bridging the gap: enhancing medication adherence for better health outcomes

Policy Updates Medical Policy & Clinical GuidelinesCommercialMay 28, 2025

Material adverse change

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Education & TrainingMedicare AdvantageMay 27, 2025

Learn about annual Model of Care training for special needs plans

Education & TrainingCommercialMedicare AdvantageMay 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 UpdatesMedicare AdvantageMay 13, 2025

Clinical Criteria updates

Effective June 20, 2025

AdministrativeMedicare AdvantageMay 1, 2025

Additional drug codes added to medical claims edit system

Education & TrainingCommercialMay 1, 2025

Streamline your prior authorizations with our digital tools

Policy Updates Medical Policy & Clinical GuidelinesMedicare AdvantageApril 30, 2025

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Effective August 1, 2025

Policy Updates Medical Policy & Clinical GuidelinesMedicare AdvantageApril 24, 2025

Medical Policies and Clinical Utilization Management Guidelines update

Effective May 25, 2025

Products & Programs PharmacyMedicare AdvantageApril 18, 2025

New specialty pharmacy medical step therapy requirement

Effective June 1, 2025
Hercessi

Products & Programs PharmacyMedicare AdvantageApril 18, 2025

Specialty pharmacy preapproval list update

Effective August 1, 2025
Jubbonti; Wyost

Policy Updates Reimbursement PoliciesCommercialApril 1, 2025

Clarification to reimbursement policy: Incident to Services and Billing Professional

Education & TrainingCommercialMedicare AdvantageApril 1, 2025

Register for our next webinar: Enhancing Diabetes Management — Focus on Standardized Metrics