Quality Measures Track Diabetes Care

Regular screenings, tests and office visits can help our members manage diabetes. Review tips on how to close care gaps.

Review Claims Reminders for Behavioral Health Services

We monitor behavioral health claims for disallowed billing practices. See guidance on billing for services provided by trainees under supervision.

Update: Watch for Changes to Behavioral Health Clinical Review Criteria for Substance Use

We’ll implement updates to the clinical criteria we use in medical necessity reviews of substance use services for adults.

Access BlueApprovR^SM in Availity^® Authorizations

The BlueApprovR utilization management tool will be integrated with Availity Authorizations in Availity Essentials. The new configuration will continue to expedite approvals for behavioral health services. Review how to submit and access prior authorization requests.

NICU Claims Submissions Should Match Prior Authorization Levels of Care

Effective Aug. 1, 2025, we’ll pay claims based on the authorized level of neonatal intensive care units in your prior authorization.

Review Prior Authorization Changes for Commercial Members

Effective July 1, 2025, prior authorization requirements for certain commercial plans are changing to reflect new, replaced or removed codes.

Explore Learning Opportunities

We offer free training for providers who participate in our networks. Sign up for sessions, including training on parent and guardian mental health.

Records May Be Requested to Comply with Risk Adjustment Data Validation Audit

Data collected through the U.S. Department of Health and Human Services’ audit helps ensure the accuracy of payments for the Affordable Care Act. Please respond to any medical record requests you receive from the Centers for Medicare & Medicaid Services in a timely manner.

Providers with Unused Record IDs May Be Terminated from Networks

If you haven’t filed a claim with us under your record ID with a date of service within 24 months, we may cancel your record ID. Review how to keep record IDs active.

Verify Your Directory Information Every 90 Days

Our members rely on our provider directory for accurate information about your practice. Review and verify your data every 90 days and update it when it changes.

Looking for Help?

Do you know the fastest way to get a response on prior authorizations? Are you aware of the latest pharmacy drug updates, or do you have a claims question? You can find many answers on our provider website, including:

• The latest updates

• Details about tools to streamline billing and processes

• Tips for newly contracted providers

• Quick reference links

Contact Your Provider Relations Representative

If you have a question and can’t find an answer, our Provider Relations Representatives are here to help. Email us or call 800‑722‑3730 and select Option 2 for network.

New Home Delivery Pharmacy Service to Fill Members’ Injectable GLP‑1 Prescriptions

Express Scripts^® Pharmacy will transition home delivery prescriptions for covered, injectable GLP‑1 drugs to a new specialized pharmacy. Effective June 15, 2025, EnGuide Pharmacy will dispense these prescriptions. Learn what’s changing.

Pharmacy Program Quarterly Update – Part 1

Changes were made to our drug lists and utilization management program. Learn about these and other pharmacy program updates.

Review New Coding Policy for Global Obstetrical Maternity Services

We have new coding guidance in our Clinical Payment and Coding Policy, CPCP044 Global Obstetrical/OB Maternity Services, effective Aug. 19, 2025.

Learn About Updates to Clinical Payment and Coding Policies

We regularly add and modify our CPCPs as part of our ongoing policy review. See which policies were updated and when.

Review Medical Policy Updates

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.