We’re on the countdown! 12 more days to AZ Blue provider portal sunset
Our provider portal transition will conclude on Tuesday, September 29 (at approximately 8 p.m.), when we will permanently close the AZ Blue provider portal. If your teams are still using resources in the AZ Blue portal, please remind them to move any remaining workflows to Availity Essentials™ as soon as possible. For more information about our portal transition, see our provider FAQs.
We have built out our AZ Blue “Payer Space” in the Availity portal to give you easy access to our proprietary content. Be sure to check out the “Applications” and “Resources” tabs. We have also enhanced many of our Availity portal transactions and resolved several AZ Blue data issues to improve self-service for you. We will continue to do this and to add new features over time.
If you have questions about registering for Availity or how to use the features, don’t hesitate to reach out to the Availity Client Services team at 800-282-4548. Availity experts will offer two webinars to show you how to save time and get the most out of what we have implemented. Register now!
Starting November 2, we will add secondary code edits to our claim processing system. This will help adjudicate claims more accurately, more consistently, and in alignment with nationally recognized coding standards and payment practices.
Secondary code edits are similar to traditional claim edits. These supplemental edits further evaluate code relationships to find anything missed in the primary code editing process. Finely tuned analytical tools assess billed services to validate appropriate coding (including the use of modifiers), avoid duplications, and identify various types of inconsistencies and discrepancies. You can preview a draft of the new secondary claim edits in our updated Medical Code Edit Guidelines (final pdf to be posted online by October 1). In the Availity portal, look in the AZ Blue Payer Space, in the Claim Coding Resources app.
New medical policy for experimental/investigational services
Effective November 1, our new medical policy for experimental and investigational (E&I) services defines the applicable criteria for E&I determinations. It includes a list of codes currently considered E&I and not covered unless otherwise specified in another medical policy used by AZ Blue. We may update the codes in this policy as new codes are created or if the E&I criteria are no longer applicable to a code.
Reminder: Contracted providers are generally prohibited from billing members for services denied as experimental or investigational.
Reminders about updates that start October 1
New medical policies
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Applied Behavior Analysis (ABA)
For dates of service on and after October 1, 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.
2026 Medicare Part B step therapy policy updates
The 2026 Medicare Part B step therapy list will reflect these updates, effective October 1:
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Added more biosimilars to the non-preferred list
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Myasthenia gravis: Updated to allow Vyvgart and Vyvgart Hytrulo regardless of the antibody subtype See the revised list for details.
Refresher on September updates (in case you missed these)
Partial hospitalization program (PHP) admissions to require prior auth and concurrent review
Effective for service dates on and after September 1, 2026, AZ Blue requires prior authorization for PHP admissions. The authorization initiates the concurrent review process to monitor clinical progress and ongoing need. Please reference MCG’s Partial Hospital Behavioral Health Level of Care guidelines (30th edition) for criteria. You can find it in 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 began doing prior authorization 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 (locations 19, 21, and 22). Prior auth is not required for location 24.
This update applies to most of our commercial plans (some self-funded groups do not currently require these site-of-service reviews). 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 have been added to the prior auth requirements code list. For member-specific requirements, use the Availity prior auth workflow or our prior auth lookup tool at azblue.com/lookup.
More info and reminders
Reminder about 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.
Reminder about our 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.
Is your NPPES data up to date?
Please check your NPPES Registry data to be sure the information associated with your NPI is accurate, including your taxonomy (specialty) and address. An out-of-date address can result in a claim being processed as out-of-network care (especially for labs and specialty pharmacies).
Grievance or appeal? What’s the difference and why does it matter?
When submitting a provider dispute request, should you call it a grievance or an appeal? Labeling your dispute request with the correct term helps us get it to the right team and processed more quickly. Learn more and see examples.
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.
Vyvgart and Vyvgart Hytrulo are registered trademarks of Argenx B.V.
MISHA is a trademark of Moximed, Inc.
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.
