Remit app now offers greater online search capacity
We have updated and renamed the Remit History app in our Availity Essentials™ payer space. The app was originally designed in 2024 to find remit history that wasn’t available through the Availity Remittance Viewer. We’ve enhanced it so you can now use it as a backup if you’re not finding a particular remit through the Remittance Viewer.
The new name for the app is Remit Statements (PDFs), and you can access it in the AZ Blue payer space in the Applications tab. While you’re there, take a moment to check out the other apps and resources we’ve posted for you!
New updates that start October 1
New medical policies
1.
Applied Behavior Analysis (ABA)
Our new proprietary ABA policy will replace the current MCG guideline for ABA services. It brings greater detail and clarity to:
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Medical necessity criteria for initiation and continuation of ABA therapy
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ABA intensity standards
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Caregiver training
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Supervision requirements
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Progress reporting and outcome data requirements
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Step-down and discharge criteria
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Documentation requirements for authorization requests
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Non-duplication of school-provided and other therapy services
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Provider qualification and credentialing requirements
The new ABA policy applies to commercial and Federal Employee Program® (FEP®) plans. It does not apply to Medicare Advantage plans.
Implantable Shock Absorbers for Treatment of Knee Osteoarthritis
This new policy will address the use of implantable shock absorber technology, including the MISHA™ Knee System, for the treatment of knee osteoarthritis. This emerging technology will be considered experimental/investigational and not covered for commercial and FEP plans. The policy does not apply to Medicare Advantage plans.
Quarterly drug fee updates
You can preview the October 1 updates starting September 1 on the Availity Essentials portal. Read more.
Coming up on 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 FEP or Medicare Advantage plans.
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.
August reminders
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.
Other recent updates
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 July 1, 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.
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, contact CMS at 1-800-MEDICARE (800-633-4227).
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 diabetes-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) are essential and why these patients must still be included in your reporting for the HEDIS diabetes measures.
Learning opportunities
For PCPs: This free, one-hour CME course equips PCPs with practical, evidence-based strategies to diagnose dementia, communicate effectively with patients and families, manage symptoms, coordinate care, and confidently guide patients throughout the dementia journey. This on-demand course features leading dementia care experts from Mayo Clinic Neurology, Honor Health, Barrow Neurological Institute, Banner Alzheimer’s Institute, and Hospice of the Valley’s Dementia Care and Education Campus. When you’re ready, you can access the module here: https://physician-dechov.talentlms.com/.
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.
The MCG care guidelines are the proprietary and copyright-protected information of MCG Health, part of the Hearst Health network.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Policy Center for Maternal Mental Health is a trademark of 2020 MOM.
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.
