Highlights

Key Updates

Quality ManagementCommercialMedicare AdvantageFebruary 1, 2025

2025 Clinical Quality in Practice webinar series


What's New

Recent Updates

Policy Updates Medical Policy & Clinical GuidelinesBadgerCare Plus and Medicaid SSI ProgramsFebruary 17, 2025

MCG Care Guidelines 29th edition

Policy UpdatesMedicare AdvantageFebruary 14, 2025

Clinical Criteria updates

Effective March 24, 2025

Quality Management Optimizing HEDIS & STARSCommercialFebruary 11, 2025

Developmental screening in the first three years of life

Quality Management Optimizing HEDIS & STARSCommercialFebruary 11, 2025

Glycemic Status Assessment for Patients with Diabetes (GSD) 2025

Quality Management Optimizing HEDIS & STARSCommercialFebruary 11, 2025

Chlamydia Screening (CHL) 2025

Quality Management Optimizing HEDIS & STARSCommercialFebruary 10, 2025

Colorectal Cancer Screening (COL-E) 2025

Administrative Digital SolutionsCommercialFebruary 4, 2025

Expansion of Carelon Medical Benefits Management, Inc. programs

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

Corrected claim guidance for the Federal Employee Program®

Policy Updates Reimbursement PoliciesCommercialFebruary 1, 2025

New reimbursement policy: Place of Service — Professional

AdministrativeCommercialMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsFebruary 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

Quality ManagementCommercialFebruary 1, 2025

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

Policy UpdatesBadgerCare Plus and Medicaid SSI ProgramsJanuary 30, 2025

Clinical Criteria updates

Effective March 7, 2025

Quality Management Optimizing HEDIS & STARSMedicare AdvantageJanuary 28, 2025

Eye Exam for Patients with Diabetes (EED) 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

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 PharmacyBadgerCare Plus and Medicaid SSI ProgramsJanuary 6, 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 AdvantageBadgerCare Plus and Medicaid SSI ProgramsJanuary 1, 2025

Enhance billing and coding accuracy with new Payment Integrity training

Products & Programs PharmacyMedicare AdvantageJanuary 1, 2025

Kroger Specialty Pharmacy acquisition

AdministrativeMedicare AdvantageJanuary 1, 2025

Announcing Health Perks — earn rewards for your healthcare activities

Policy Updates Medical Policy & Clinical GuidelinesCommercialJanuary 1, 2025

Medical Policies and Clinical Guidelines updates — December 2024

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

2025 FEHB and PSHB information available online

Products & Programs PharmacyMedicare AdvantageDecember 31, 2024

Important information about specialty prescriptions

Administrative Digital SolutionsCommercialMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsDecember 30, 2024

Enhance patient coordination with Total Member View

Products & Programs PharmacyCommercialDecember 27, 2024

Weight management program overview