When a patient receives a scary, life-altering diagnosis or faces an urgent barrier to care, getting help quickly can make all the difference. AZ Blue’s Clinical Rapid Response Team partners directly with providers and members to help clear the path to prompt diagnosis, treatment, and access to specialty care. The team serves as a single point of coordination for urgent, high-impact situations. Team members coalesce to help accelerate approvals, facilitate timely appointments, navigate complex benefit and network issues, and connect members with additional care management and community resources.
Available 24/7 through a dedicated and escalated intake process, the Clinical Rapid Response Team focuses on members who are being evaluated, recently diagnosed, or actively receiving treatment for serious conditions and delays in care could have significant consequences. Working across clinical operations, care management, pharmacy, provider partnerships, and utilization management, the team mobilizes to ensure the member receives the right support at the right time while reducing administrative burden for providers.
The Clinical Rapid Response Team prioritizes and troubleshoots critical needs as quickly as possible. Most cases are resolved within 24 hours and almost all within 48 hours. To request urgent clinical assistance or refer a patient, send a brief email to rapidresponse@azblue.com.
Updates effective September 1
Partial hospitalization program (PHP) admissions to require prior auth and concurrent review
Effective for service dates on and after September 1, 2026, AZ Blue will require prior authorization for PHP admissions for behavioral health conditions. The authorization will initiate the concurrent review process to monitor clinical progress and ongoing need. Initial and ongoing reviews will align with MCG’s Partial Hospital Behavioral Health Level of Care guidelines (30th edition). You can access this care guideline via the Availity Essentials™ portal at “AZ Blue Payer Space > Applications > Prior Authorization and Medical Policies > AZ Blue Plans > Medical Policies > MCG Care Guidelines.”
Note: This update applies only to our commercial plans. It does not apply to Federal Employee Program® (FEP®) or Medicare Advantage plans.
Change in effective date: Place/site-of-service review required for minor procedures performed in outpatient hospital settings
Effective September 1, 2026, we will begin doing preservice reviews for certain types of minor elective services (i.e., colonoscopies, EGDs, knee and shoulder arthroscopies, lithotripsies, and hernia repairs) when scheduled to be performed in hospital outpatient facilities. In this setting, the services will be considered medically necessary only if the patient’s age or health condition meets certain criteria for a higher level of care. If not, the services must be performed in an ambulatory surgery center. The place-of-service review process will also consider logistical and access challenges related to the member’s location and circumstances.
This update applies only to our commercial plans. It does not apply to FEP or Medicare Advantage plans. For details, please see the new Site of Service for Outpatient Procedures medical policy (includes a list of the applicable procedure codes on page 7). Applicable codes and messaging will also be added to the prior auth requirements code list, lookup tool, and Availity prior auth workflow.
What starts August 1
Outpatient observation services
Effective for service dates on and after August 1, 2026, observation service code G0378 will only be eligible for reimbursement when the observation period meets or exceeds eight hours. Observation for less than eight hours is included in the payment for services, including but not limited to emergency room visits and critical care. See the updated Included Services Pricing Guidelines.
Please report hourly observation services with HCPCS code G0378 (hospital observation service, per hour) under revenue code 0762. When medically necessary and documented, a maximum of 72 hours of outpatient observation services is payable.
Note: This update applies to members with AZ Blue commercial, FEP, and BlueCard® (out-of-area) plans. Medicare Advantage plans follow specific CMS pricing and payment rules.
What started in July
Separate Medicare program covers GLP-1 medications to support weight loss
On July 1, 2026, CMS launched a short-term GLP 1 Bridge Program (ends December 31, 2027). The program offers weight loss support for those enrolled in Medicare Part D and not currently using GLP-1 medications for diabetes or other non-weight loss conditions. CMS runs this stand-alone program directly, including eligibility, prior authorizations, claims, and pharmacy payments. Health insurance payers are not involved in any aspect of it.
Note: Anyone currently covered under Part D for GLP-1 medications will not transition to the CMS Bridge Program.
For more information about this new program, see the CMS Information for Providers page. If you have questions, feel free to contact CMS at 1-800-MEDICARE(800-633-4227).
Standard prior authorization penalty policy change
Partnering with providers through the prior authorization process helps ensure the best clinical outcomes for our members. We’re committed to making the request process easy and efficient for you. To further strengthen prior authorization compliance, we have updated our standard penalty policy for most AZ Blue commercial plans. For dates of service on and after July 1, when a required prior auth is not obtained, the claim (or claim line) for that service will be denied. Billing the member for the service is not permitted. Get the details.
Expansion of our jointly administered benefit plans
This line of business allows large, self-funded groups to manage their benefit plan through AZ Blue and a third-party administrator (TPA). Effective July 1, seven groups have switched from their current plan to a jointly administered plan. AmeriBen or American Health Group administer medical policy and prior authorization for these groups. For more information, see the jointly administered plan overview and UM contact information.
Effective for service dates on and after July 1, we have updated ABA fees for CPT® codes 97151 through 97158. We have also added new pricing actions for modifiers HN, HO, and HP when billed with these codes. For more information about these modifiers, see the updated Modifier Pricing Actions list.
Prefix list update
Our 07/01/2026 prefix list includes seven new prefixes for groups now enrolled in jointly administered plans. It also includes one new group-specific prefix (YCY). Another prefix (UYU) has been discontinued because the group is switching to a Strategic Hub plan using prefix AOZ. For more information about prefixes and prefix replacements, visit azblue.com/prefix.
You can access the annual fee schedule updates (effective July 1) via Availity Essentials. Go to the AZ Blue payer space (applications tab) and open the Claim Pricing Resources app. Learn more about our updates.
Reminders
We’re now using MCG 30th edition
For service dates on and after June 16, we’re now using the 30th edition of the MCG care guidelines. To access the guidelines, visit Availity Essentials > Payer Spaces > AZ Blue > Prior Authorization and Medical Policies > AZ Blue Plans > Medical Policies.
30-day readmission policy update
Claims for acute care hospital readmissions that occur within 30 days after discharge are reviewed in relation to the initial hospitalization to evaluate the circumstances. As of June 1, if the readmission is determined to be a continuation of care and the claim is for the same DRG as the original claim, the claim for the readmission will be denied as included in the primary admission. If the claim is for a similar DRG, it will go through further review by a clinician.
Non-reimbursable modifiers: Certain modifiers indicate that an external funding source holds financial responsibility (i.e., HU, HV, HW, HX, HZ, QJ, SE, SL). AZ Blue will not reimburse for these. See the revised Modifier Pricing Actions List.
Please use code E11.A for Type 2 diabetes in remission and keep those patients in your HEDIS® reporting
The E11.A diagnosis code indicates that a patient is considered to be in remission, according to these three CMS criteria:
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No current diabetics-related complications
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No longer on any diabetes medications, including GLP-1 agonists for the treatment of diabetes
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Hb A1c level has been ≤6.5 for at least three months after stopping diabetes medications
Note: Past damage, silent complications, and reversibility remain serious risks for patients in remission. That’s why ongoing monitoring and reporting of diabetes-related care (e.g., A1c labs, blood pressure screenings, eye exams, and kidney testing) is essential and why these patients must still be included in your reporting for the HEDIS diabetes measures
2 ways to avoid claim and appeal delays
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Use the claim barcode letter as the cover sheet for your records! The barcode letter is how we connect your records to the correct claim. Without it, we can’t finish processing the claim and may have to deny it.
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Use a cover sheet and slim down the records for your appeals.
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Be sure to use your grievance form or other request summary as a cover sheet for your appeal.
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Send only the documentation that pertains to your appeal (rather than the entire patient record). This will help us more quickly identify what you’ve sent as an appeal, so it can be directed to the correct team for review.
Availity is a separate, independent company contracted with AZ Blue for provider portal services. Availity is a registered service mark and Availity Essentials is a service mark of Availity, LLC.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
The MCG care guidelines are the proprietary and copyright-protected information of MCG Health, part of the Hearst Health network.
Blue Cross, Blue Shield, the Cross and Shield Symbols, Federal Employee Program, FEP, and BlueCard are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
