Aetna has released a series of policy updates that will significantly impact providers across Medicare Advantage and commercial plans, particularly in the areas of pre-approvals, coding, and billing compliance. These changes, effective between late 2025 and early 2026, are expected to reshape workflows for eligibility verification, billing, and collections.
Effective January 1, 2026, Aetna will require prior authorization through EviCore for inpatient rehab, skilled nursing, and certain home health services.
Impact: Eligibility verification teams must ensure pre-approvals are secured before billing. Claims submitted without authorization face a high risk of denials, leading to rework and appeals.
Aetna has reinforced its “site of care” requirements for specific infusion and injection drugs such as Avastin and Krystexxa.
Impact: Reimbursement will depend on service location. Providers must confirm approved sites during eligibility checks and prior to scheduling or billing.
New specialty drugs and certain procedures have been added to Aetna’s National Precertification List, with implementation dates spanning 2025–2026.
Impact: Eligibility verification must confirm precertification status for relevant CPT/HCPCS codes. Claims lacking valid precertification will be denied.
Starting January 1, 2026, new HCPCS codes will apply to non-covered compression stocking supplies.
Impact: These items are not covered by Aetna and should be billed directly to patients where applicable
From November 1, 2025, Aetna will apply clarified CPT guidance for coding skin and subcutaneous lesion excisions.
Impact: Coders must follow the updated rules to avoid billing denials.
Beginning December 1, 2025, Aetna will require proof of patient adherence for CPAP therapy. This must be documented using specific G-codes.
Impact: Claims without adherence documentation will be denied. Billing and eligibility verification teams must confirm compliance before submission.
Industry Outlook
These changes underscore Aetna’s ongoing shift toward tighter utilization management and documentation-driven reimbursement. Providers are urged to update internal workflows, retrain coding teams, and strengthen eligibility verification processes well ahead of the effective dates to minimize claim denials and payment delays.
September 16, 2025 | Washington, D.C. - The Centers for Medicare and Medicaid Services (CMS) announced today the introduction of the Rural Health Transformation Program, a historic program designed as a result of the Working Families Tax Cuts Act, which will cost $50 billion. The program is supposed to enhance health care delivery to rural America by increasing access, enhancing quality of care, and establishing sustainability in the long term.
U.S. Health and Human Services Secretary Robert F. Kennedy, Jr., called the effort the largest investment in enhancing health care among rural Americans, stating that it concentrated on delivering dignity and reliable care. Dr. Mehmet Oz, the Administrator of CMS, referred to the program as a historic investment, which would not just create a systemic change but also enhance results across generations.
The program welcomes all 50 states to apply for the funding to develop state-based solutions to the rural health issues. There will be five strategic goals that will be funded:
The funding will be issued in five years, starting in FY 2026, whereby it will allocate 10 billion for each year. Half will be allocated equally to states with approved applications, with the remaining half released to those with the greatest potential impact.
The application deadline is November 5, 2025, and the award will be announced by December 31, 2025. CMS will offer continuous monitoring to make sure that it is implemented successfully.
States can visit the CMS site at: CMS Rural Health Transformation Program to find information and materials on the application.
The Texas Medicaid and Healthcare Partnership (TMHP) has announced the adjustments to the processing of the claims for services delivered under Medicaid only by the dual-eligible clients when they are subscribers to managed care organizations (MCOs).
TMHP will not adjudicate these claims after September 1, 2025, when the date of service (DOS) falls or later. Instead, they will be passed on to the MCO of the client of TMHP and adjudicated. Response to claims will have this forwarding ,but TMHP will not produce an Electronic Remittance and Status (ER&S) Report. Adjudication information has to be obtained by the providers themselves from the MCO.
In the Rider 32 Procedure Code List, a list of procedure codes transitioned is provided. The providers are also advised to consult the corresponding article "Rider 32 Provider EVV Impacts" regarding how to make claims regarding services that need Electronic Visit Verification (EVV).
Exempt Programs
The existing programs will not be exempt from the MCO transition and will still be handled under TMHP:
Claim Submission Guidance
The healthcare providers who have been utilizing TexMedConnect or electronic data interchange (EDI) have to submit claims to one payer. The claims that include information that will be paid by both TMHP and an MCO will be refused and should be submitted separately. The modifiers used in all claims should be right, as in the Texas Medicaid Provider Procedures Manual.
Provider/ MCO Responsibilities
The providers are required to continue providing authorized services, to review the previous authorizations with the MCO, and to make claims based on the out-of-network process of each MCO.
MCOs are required to:
Assistance
Compliance is a characteristic feature of the quality of patient care and operational integrity, as well as the trust in the healthcare environment. The agencies like the Office for Civil Rights (OCR), the Centers for Medicare and Medicaid Services (CMS), and The Joint Commission have become more vigilant, and these unannounced audits are becoming very common.
In the case of the healthcare provider, the consideration of compliance in healthcare extends far beyond regulatory fines. It protects data on patients, guarantees billing, and strengthens the reputation of an organization. However, since audits can come as a surprise, most providers will be struggling to put their documents together, sort out discrepancies, and other loopholes, usually at the cost of the day-to-day operations. Actual audit preparedness eliminates such scrambling and takes its place with a confident, aggressive pose.
Why Compliance Matters Now
Compliance is the most crucial aspect of healthcare that is most observable in three aspects that affect each other: sensitive information protection, financial integrity, and safe and high-quality care.
At the data level, HIPAA and HIT regulations impose stringent requirements on the protection of both the protected health information (PHI) and the personally identifiable information (PII), which require the implementation of strong security controls to avoid breaches. CMS and the Office of Inspector General (OIG) have become more financially vigilant on the billing practice, including the documentation of medical necessity and preventing improper claims. In practice, the inspections by The Joint Commission examine the compliance with patient safety protocols, infection prevention, and emergency preparedness in real time.
Failure to comply with any of these aspects may lead to fines, repayment claims, public enforcement measures, and, most importantly, patient mistrust. Continuous compliance is a strategic requirement and not a compliance department box as a result of that risk.
Audit Readiness as an Advantage
"Audit-ready" refers to the ability to demonstrate clean and up-to-date evidence at any time. Maintain clinical, operational, and financial records in a well-ordered and retrievable manner. Every diagnosis, treatment, and code should have a defensible trail.
It takes everyone:
Close the Gaps That Cause Findings
Strong programs still stumble on small lapses: missing PHI or PII access logs, mismatches between notes and billing, or outdated policies. Often, the issue is uneven policy use across departments, not intent.
Regulators now focus more on PII as cyberattacks grow. Weak storage, loose access, or poor monitoring of PII can trigger both incidents and violations. Treat PII as a high-priority risk.
Strengthen PII Compliance
PII protection starts with accountability and touches every workflow. Access with minimum privilege and schedule the review. Encrypt stored and moving data. Do not just do it on an annual basis; employ scenarios to enable the staff to make swift decisions when pressure sets in.
PII Compliance Checklist
Do not let plans sit idle. Test, review, and demand proof from vendors. Turn the checklist into daily practice.
Use Modern Compliance Software
Technology now shapes audit durability. Leading platforms integrate with the EHR, preserve tamper-evident audit trails, watch PHI and PII access in real time, and flag anomalies for quick review. Automation trims manual effort and keeps HIPAA, CMS, and Joint Commission evidence current.
Make Compliance Continuous
Sustainable programs are premised on round-the-clock observation as opposed to scrambling at the nick of time. Use live notifications and in-house audits, which are a reflection of regulators, and prompt resolutions. Train through practice, establish expectations, and ensure competence. In cases where compliance is daily work, planned and surprise surveys can be conducted without interfering with care.
Run the Audit Smoothly
Name one audit lead to control communications. Keep a central library of policies, reports, and training records so evidence is ready. Answer only within the request scope to limit exposure. Update leadership at each step for aligned decisions and messaging.
Bottom Line
Adherence safeguards patients, stabilizes processes, and develops trust. By matching talented individuals with trained procedures and the appropriate tools, teams remain audit-ready throughout the year and make compliance a true competitive advantage.
Following its announcement of the Wasteful and Inappropriate Service Reduction (WISeR) Model, the Centers for Medicare & Medicaid Services (CMS) released an FAQ page, thirteen items as of August 12, 2025. The FAQs address implementation details, guardrails, and expected impacts on patient safety, data privacy, and Medicare savings. They also cover participant compensation and the denial and appeals pathway, and note how the WISeR Model aligns with CMS and HHS leadership commitments to improve prior authorization.
Participant Compensation And Safeguards
Model participants, who use AI-assisted tools to review targeted services, are paid as a percentage of the savings their reviews generate. Any potential denial must be reviewed by a human clinician; AI alone cannot deny a claim. CMS will audit participant decisions against Medicare coverage criteria, assign quality scores, and may levy financial penalties or remove participants from the model for high inaccuracy.
Prior Authorization Non-Affirmation
If a prior authorization request is non-affirmed or denied, the provider or supplier may resubmit an unlimited number of times at the participant’s processing expense. Providers and suppliers may still furnish the service and submit a claim to the Medicare Administrative Contractor (MAC). The MAC may approve or deny the claim. A denial constitutes an initial payment determination and is subject to existing administrative appeal processes for providers, suppliers, and people with Medicare.
Timeline And Scope
The WISeR Model is scheduled for a six-year launch beginning January 1, 2026, in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
Avoid denials by using the state-required codes and modifiers whenever a member’s ISP renews.
Effective immediately, when a STAR+PLUS member’s individual service plan (ISP) renews, long-term care providers must bill certain respite and assisted living services with the updated HCPCS procedure codes and modifiers. This aligns with Texas’s new payment approach for nursing facilities and HCBS. Claims filed with the old codes will be denied.
New payment methodology
To prepare for the payment transition, HHSC updated the LTSS billing matrix in August 2025 for STAR+PLUS HCBS services.
Beginning September 1, 2025, HHSC shifted from the RUG-III model to the Patient-Driven Payment Model (PDPM). Under PDPM, providers and nursing facilities can expect a system that:
Next steps
The shift from RUG-III to PDPM will roll out as each member’s ISP is reviewed and renewed. If you serve multiple members in facility or community settings, your transition may span up to a year, finishing as soon as all ISPs are renewed. During this period:
Before an ISP renews: Continue billing under RUG-III using the current procedure codes and modifiers.
At renewal: You’ll receive prior authorization tied to the updated ISP, delivered via the UnitedHealthcare Provider Portal or by fax from the service coordinator.
After renewal (next transaction): Switch to the updated codes and modifiers:
STAR+PLUS LTSS claims:
Use the correct state-required modifiers listed on the state’s Payment Rate Information page.
Important: Reimbursement under PDPM requires the updated codes. Claims with discontinued codes will be denied and must be resubmitted as corrected claims.
Here’s How You Can Prepare
Before your first renewal, make sure to:
Check HHSC for the latest STAR+PLUS payment rates.
Review LTSS Codes & Modifiers Guide, focusing on:
Centers for Medicare & Medicaid Services (CMS) has suggested some major changes in remote patient monitoring (RPM) and remote therapeutic monitoring (RTM) reimbursement in its CY 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule, published July 16, 2025, in the Federal Register.
The proposal encourages new billing codes, reduces existing thresholds, and increases reimbursement pathways to be more consistent with clinical practice in the field.
Key Proposed Changes:
Device Supply and Data Transmission: A new code (99XX4) would be used to bill 2-15 days of data transmission that would be reimbursed at the same rate as the existing 16-day code (99454).
Treatment Management Services: A new code (99XX5) would replace 10-20 minutes of clinical interaction each month at approximately half the current rate (99457).
RTM Updates: 2-15 days of data and 11- to 20-minute interactions would be codeable and would incur proportionally less work relative value units (wRVUs).
Summary Table
| Area | Current Requirement | Proposed CY 2026 Update |
| RPM Data Transmission | ≥ 16 days/month (CPT 99454) | New code 99XX4 for 2–15 days, reimbursed at the same rate as 99454 |
| RPM Treatment Mgmt. | ≥ 20 min/month (CPT 99457) | New code 99XX5 for 10–20 minutes (≈ half reimbursement) |
| RTM Data Transmission | ≥ 16 days/month | New device codes for 2–15 days of data collection |
| RTM Treatment Mgmt. | ≥ 20 min (98980/98981) | Revised codes for 11–20 minutes with reduced wRVUs |
CMS said the reforms would modernize utilization and eliminate operational barriers, as well as promote preventive and value-based care models. Reduction of thresholds would increase beneficiary access, aid in care transition after discharge, and improve population health management within plans such as the Medicare Shared Savings Program (MSSP).
Nevertheless, CMS focused on compliance and referred to a recent DOJ False Claims Act settlement of 1.29 million, in connection with non-compliant RPM practices. The agency cautioned that fraud and abuse enforcement could be initiated by improper billing.
The comment window on the proposed rule is open till September 12, 2025, and a final rule is likely to follow later this year. Provided that it is adopted, changes would become effective January 1, 2026.
The Health and Human Services Commission (HHSC) has announced that FEI Systems will conduct its monthly provider demonstration for the Critical Incident Management System (CIMS) on September 9, 2025, from 10:00 a.m. to 11:00 a.m.
The monthly demonstrations are designed to assist providers in effectively using CIMS. HHSC strongly encourages providers to take part in these live training opportunities to enhance their understanding and use of the system.
The webinars are open to:
Providers can register by logging into CIMS, selecting ‘Help’ at the top right of the dashboard, navigating to ‘Training’, and then choosing ‘Register for Provider Demonstrations’ from the course list.
For questions or additional information, providers may contact MCS_CIMS@hhs.texas.gov.
This notice revises the July 28, 2025, tmhp.com article titled “Prior Authorization Requests for DMEPOS Replacements Due to the Central Texas Floods Being Expedited.” TMHP is expediting processing for new prior authorizations and recertifications to replace flood-impacted DMEPOS and is waiving submission time frames and documentation requirements for those new replacement requests.
Important Updates
TMHP has lifted the requirement that clients be permanent residents of a disaster-designated county. Expedited prior authorization is available statewide through September 29, 2025, for Texas Medicaid and CSHCN clients who were affected by the 2025 Texas flooding in a declared disaster county. To qualify for the expedited process, providers must state that the request is due to the 2025 Central Texas floods and explain why the DMEPOS must be replaced.
Requirements for Expedited Prior Authorization
In the PA, state the need is due to the 2025 Central Texas floods and explain why replacement is required.
Keep documentation that DMEPOS were lost, destroyed, irreparably damaged, or unusable due to flooding.
Note: Services may be subject to retrospective medical-necessity review.
For help, call 800-925-9126 (TMHP Contact Center) or 800-568-2413 (TMHP-CSHCN).
Starting Nov 01, 2025, UnitedHealthcare will require prior authorization for physical, occupational, and speech therapy for UnitedHealthcare Community Plan members ages 3 and older in Kansas, North Carolina, and Virginia. In North Carolina, this change also expands the requirement to include members ages 21 and older.
Prior authorization is required for the entire plan of care (initial eval excluded) for outpatient PT/OT/ST.
Applies to new and current therapy patients. Submit starting Oct. 1, 2025, for DOS on/after Nov 01, 2025
North Carolina: Applies to all PT/OT/ST patients, under and over 21.
Additional Information
For patients already in care, submit treatment plans for dates of service on or after Nov 01, 2025, for medical necessity review. A prior authorization request is still required to ensure claims are paid. When submitting PT/OT/ST requests, include the following documentation:
Documentation to include (PT/OT/ST):
How to submit: Use the Prior Authorization & Notification tool in the UnitedHealthcare Provider Portal.
Exclusions:
Resources: The program FAQ covers exclusions, impacted CPT® codes, clinical examples, and the authorization/claims workflow.
