Highlights

Key Updates

Quality ManagementCommercialMedicare AdvantageFebruary 1, 2025

2025 Clinical Quality in Practice webinar series


What's New

Recent Updates

Policy Updates Reimbursement PoliciesCommercialFebruary 1, 2025

New reimbursement policy: Place of Service — Professional

Products & Programs Federal Employee Program (FEP)CommercialFebruary 1, 2025

Corrected claim guidance for the Federal Employee Program®

AdministrativeCommercialMedicare AdvantageFebruary 1, 2025

New Communication Center added to Availity Essentials

Products & Programs PharmacyCommercialFebruary 1, 2025

Pharmacy information available on our provider website

Quality ManagementCommercialMedicare AdvantageFebruary 1, 2025

2025 Clinical Quality in Practice webinar series

Products & Programs PharmacyCommercialFebruary 1, 2025

Designated specialty pharmacy network updates

AdministrativeCommercialFebruary 1, 2025

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Medical records needed for accurate payment of certain facility inpatient claims

Quality ManagementCommercialFebruary 1, 2025

Avoidance of Antibiotics Treatment for Acute Bronchitis/Bronchiolitis (AAB)

Policy Updates Reimbursement PoliciesCommercialFebruary 1, 2025

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Reimbursement policy update: Diagnostic Radiopharmaceuticals and Contrast MaterialsProfessional and Facility

Education & TrainingMedicaid Managed CareFebruary 1, 2025

Join our Provider Advisory Council

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 28, 2025

Eye Exam for Patients with Diabetes (EED) 2025

Policy UpdatesMedicaid Managed CareJanuary 28, 2025

Clinical Criteria updates

Effective March 1, 2025

Products & Programs PharmacyCommercialJanuary 27, 2025

Key formulary updates: effective January 1, 2025

Quality Management Optimizing HEDIS & STARSCommercialJanuary 22, 2025

Breast Cancer Screening (BCS-E) 2025

Quality ManagementCommercialJanuary 22, 2025

Statin Therapy for Patients with Cardiovascular Disease (SPC) 2025

Quality Management Optimizing HEDIS & STARSCommercialJanuary 21, 2025

Eye Exam for Patients with Diabetes (EED) 2025

Quality Management Optimizing HEDIS & STARSCommercialJanuary 21, 2025

Controlling High Blood Pressure (CBP)

Quality ManagementCommercialJanuary 17, 2025

Adult Immunization Status (AIS‑E) 2025

Quality Management Optimizing HEDIS & STARSCommercialJanuary 16, 2025

Asthma Medication Ratio (AMR) 2025

Quality Management Optimizing HEDIS & STARSCommercialJanuary 16, 2025

Kidney Health Evaluation for Patients With Diabetes (KED) 2025

Products & Programs Federal Employee Program (FEP)CommercialJanuary 14, 2025

Authorization for post‑acute care services for FEP members

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 13, 2025

Statin Therapy for Patients with Cardiovascular Disease (SPC) 2025

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 13, 2025

Colorectal Cancer Screening (COL‑E) 2025

Quality ManagementMedicare AdvantageJanuary 13, 2025

Kidney Health Evaluation for Patients With Diabetes (KED) 2025

Quality Management Optimizing HEDIS & STARSCommercialJanuary 13, 2025

Medication Adherence 2025

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 12, 2025

Medication Adherence 2025

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 9, 2025

Advanced Illness and Frailty 2025

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 9, 2025

Transition of Care (TRC) 2025

Quality ManagementMedicare AdvantageJanuary 8, 2025

Breast Cancer Screening (BCS-E) 2025

Products & Programs PharmacyMedicaid Managed CareJanuary 8, 2025

New specialty pharmacy medical step therapy requirements

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 7, 2025

Follow‑up After Emergency Department Visit for Patients With Multiple High‑Risk Chronic Conditions (FMC) 2025

Products & Programs PharmacyMedicaid Managed CareJanuary 7, 2025

Prior authorization updates for medications billed under the medical benefit

Effective March 1, 2025
Kisunla and Piasky

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 6, 2025

Adult Immunization Status (AIS‑E) 2025

Quality Management Optimizing HEDIS & STARSCommercialJanuary 6, 2025

HEDIS Desktop Reference Guide for Commercial 2025

Education & TrainingCommercialMedicare AdvantageMedicaid Managed CareJanuary 1, 2025

Enhance billing and coding accuracy with new Payment Integrity training

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Review the Value-Added Benefits and Social Determinants of Health program

AdministrativeMedicaid Managed CareJanuary 1, 2025

Updates to correct coding editing

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Medicaid provider orientation

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Behavioral health provider orientation

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Nursing facility webinar

Education & TrainingMedicaid Managed CareJanuary 1, 2025

You are invited: Hospice webinar

AdministrativeMedicare AdvantageJanuary 1, 2025

Announcing Health Perks — earn rewards for your healthcare activities

Products & Programs Federal Employee Program (FEP)CommercialJanuary 1, 2025

2025 FEHB and PSHB information available online

Policy Updates Medical Policy & Clinical GuidelinesCommercialJanuary 1, 2025

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Medical Policies and Clinical Guidelines updates — December 2024

Behavioral HealthMedicaid Managed CareJanuary 1, 2025

Guidance for mental health and addiction services providers

Products & Programs PharmacyMedicare AdvantageJanuary 1, 2025

Kroger Specialty Pharmacy acquisition