October 2026 Provider News

Date: 10/29/26

In this issue:

General Updates - Payspan Migration Zelis, Coverage and Billing Changes for Certain Services for Members Age 18 and Younger
Quality - BCS, COL, EED, Influenza, Health Literacy Month, Osteoporosis management in women
Tribal - IHCP Resources
Clinical & Payment Policies and Prior Authorization Updates - Payment policy updates
Pharmacy Updates - Gender Affirming Care Drugs - Non-Contracted Effective 10/13/2026 for members 18 years of age and younger, Pharmacy Clinical Policy Updates
Wellcare - Provider Resources
Apple Health Core Connections - National Adoption Month & Resources for Adoptees
Training/Education - Promoting Understanding and Healing in Adoption and Foster Care Trauma Informed Interventions: Supporting Healthy Behaviors in Trauma Exposed Youth Maintaining a Healthy Professional Life: The Science Behind Self-Care That Makes Sensory: Understanding Sensory Processing Differences in Children TIC: Understand & Reduce Traumatic Reactions in youth Coping with Holiday Stress with Youth

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General Updates

Payspan Migration Zelis

With Zelis’ acquisition of Payspan we’re pleased to announce that Coordinated Care is transitioning to Zelis for both claims and non-claims payments.

The transition to the new payment platform will occur in phases, with Medicare, Medicaid, Behavioral Health, and Ambetter programs moving throughout November, December, and into early 2027. To ensure uninterrupted access to electronic payments and remittance information across all participating lines of business, we encourage you to enroll with now. Once enrolled, any additional eligible lines of business that move to the new platform will automatically be included, and no further action will be required.

How This Impacts You

In partnering with Zelis, we’re excited to offer you more efficiency and choice in how you receive claims payments and remittance data. Your options include:
- ZAPP Edge - direct settlement into the provider’s bank account via ACH plus data and performance insights from 550+ payers in a single portal
- Virtual Card (VCC) - one-time use virtual card
- ePayment Center - cost-free standard EFT/ERA solution that delivers payment via ACH
- Paper Check - free paper check delivery via USPS (default payment method)
Through this new partnership, you’ll gain access to Zelis’ premium payer payments experience, ZAPP Edge, which offers payments, data, and financial performance insights from 550+ payers in a single portal.

What You Need to Know

If you’re already enrolled with Zelis payments on ZAPP Edge to receive claim payments via ACH or VCC, no action is needed. Payments will be routed according to your current preferences under your Zelis agreement.
If you’re not enrolled with Zelis payments on ZAPP Edge, to avoid any disruption to your payment preferences, act now and select your preferred electronic payment method using the contact information below:
- ZAPP Edge or VCC: call a Zelis Advisor at 877-828-8770
- CenteneClaims Payment ePayment Center (free standard EFT/ERA)
If you are not already enrolled with Zelis for VCC or ZAPP Edge and do not enroll in the free ePayment Center, payments will be sent via paper check through the USPS.
If you receive non-claims payments, you may have additional registration steps to complete. Registration for non-claims payments can be completed by navigating to CenteneAlternativePayments.epayment.center

More information on this process will be provided closer to the transition period.

Questions

Coordinated Care and Zelis are committed to supporting you throughout this transition. If you have questions about your payment options, need additional help making your selection, or want to change your payment method please use the contact information below.

ePayment Center: 855-774-4392 or email: help@epayment.center
ZAPP Edge or VCC: Contact Zelis Client Services at 877-828-8770

Important Update: Coverage and Billing Changes for Certain Services for Members Age 18 and Younger

A new federal regulation prohibits states from using federal Medicaid funds to pay for certain gender-affirming care (GAC) for minors, referred to as “sex-rejecting procedures.” This regulation goes into effect on October 13, 2026. See 91 Fed. Reg. 52406 (August 13, 2026) (adding new Subpart N to 42 CFR Part 441) -16508 (91 FR 52406). Accordingly, effective October 13, 2026, the Health Care Authority (HCA) will use state funds to pay for these services.

What is changing?

Beginning October 13, 2026, certain services provided to members age 18 and younger will transition from Managed Care Organization (MCO) reimbursement to Fee-for-Service (FFS) reimbursement.

Affected services may include:

Certain inpatient procedures
Certain outpatient procedures
Physician-administered medications
Certain medications dispensed by pharmacies

What providers need to know

These services will continue to be covered for eligible members.
Providers should expect the payer for affected services to change from the member's MCO to Fee-for-Service (FFS).
HCA is updating ProviderOne and pharmacy systems to support FFS reimbursement.
Additional billing guidance, coding information, and implementation details will be shared by HCA as they become available.
HCA and health plans will work together during implementation to help ensure claims are processed appropriately.

Member Impact

There is no action required from members, and no disruption in access to covered services is expected. Members should not notice a change other than how these services are funded and reimbursed.

Additional Information

HCA will provide updated billing guidance, coding requirements, and drug coverage information, including updates to Provider Billing Guides and applicable drug lists. Providers should watch for future communications regarding implementation and billing instructions.

Optum EDC Analyzer

Coordinated Care is committed to continuously improving its claims review and payment processes. Effective 3/1/2027, we will begin using CMS guidelines and CPT code descriptors to deny ED Facility level 4 and 5 claims based on the below descriptions.

CMS indicates facilities should bill appropriately and differentially for outpatient visits, including emergency department visits. To that end, CMS coding principles applicable to emergency department services provide that facility coding guidelines should: follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code; be based on hospital facility resources and not based on physician resources; and not facilitate upcoding or gaming.

Overview of Coordinated Care’s E&M Program;

This denial policy applies to services reported using the UB-04 claim form or its electronic equivalent (i.e., 837I) or its successor form.
Network and non-network facility emergency departments (including hospital emergency departments).
Free standing emergency departments (UB-04 claims).
Level 4 and 5 E/M codes only.
Providers set-up to price via EAPG logic are exempt.

It is the policy of the Plan to require providers to comply with CMS coding principles when billing for emergency department services.

Facilities may receive a denial for the code level submitted to reflect a lower E/M code should have been billed, calculated by the EDC Analyzer. For certain facilities who experience denials to a level 4 and 5 E/M code, providers can re-bill with the appropriate level E/M code.

Policy Number	CC.PP.064
Policy Name	Emergency Department (ED) Evaluation and Management (E&M) Coding for Facility Claims
Line of Business Impacted	Medicaid

EX Codes:

AMISYS: EXR5 (E/M CODE DENIED. REBILL WITH APPROPRIATE LEVEL E/M CODE)
- CARC: 16
- RARC: M51

Thank you for your continued participation and cooperation in our ongoing efforts to render the highest quality health care to our members

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Quality.

Breast Cancer Screening (BCS)

Aside from some forms of skin cancer, breast cancer is the most common cancer among American women, regardless of race or ethnicity. Screening can improve outcomes. Early detection reduces the risk of dying from breast cancer and can lead to a greater range of treatment options and lower health care costs.

Colorectal Cancer Screening (COL)

Treatment for colorectal cancer in its earliest stage can lead to a 90 percent survival rate after five years. However, more than a third of adults 50-75 do not get recommended screenings. Colorectal cancer screening of asymptomatic adults in that age group can catch polyps before they become cancerous or detect colorectal cancer in its early stages, when treatment is most effective.

Eye Exam for Patients with Diabetes (EED)

Left unmanaged, diabetes can lead to serious health conditions, including vision loss and blindness. Regular eye exams are the best way to reduce the risk of blindness and maintain a healthy and productive life.

Medicaid Quality

Influenza

Influenza is a serious disease that is characterized by a variety of symptoms related to the nose, throat and lungs that can range in severity and lead to hospitalization and death.

October is Health Literacy Month

A friendly reminder that clear communication can make a meaningful difference for your patients. A few simple ways to support understanding:

Use plain, everyday language and focus on the most important next steps.
Take a moment to check that patients understand their care and next steps.
When language assistance is needed, connect patients with qualified interpreter services.

For help accessing language assistance or interpreter services, contact Provider Services:

Ambetter: 1-877-687-1197
Medicaid: 1-877-644-4613

Wellcare Quality

Osteoporosis Management in Women Who Had a Fracture (OMW)

Osteoporosis is the most common metabolic bone disease and is characterized by low bone mineral density and structural deterioration of bone tissue, causing bone fragility and increasing the risk of fractures.

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Tribal

IHCP Resources

IHCPs have access to a dedicated email inbox for inquires regarding all lines of business at Coordinated Care (Medicaid, Marketplace/Exchange, and Medicare Advantage). Please don’t hesitate to reach out to IndianHealthCareProviderAssistance@coordinatedcarehealth.com and the team monitoring the inbox will assist or connect you with the appropriate contacts to resolve your questions.

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Clinical & Payment Policies and Prior Authorization Updates

Clinical Policy Updates

The following policies are updated as of the listed Effective Date. Policies are posted on the Coordinated Care of Washington Policy webpage.

New to List?	Policy #	Policy Title	Line of Business	Change Type	Effective Date
	WA.CP.BH.528	HRSN - Intensive Behavioral Supportive Supervision	Apple Health	Revised	10/1/2026
	CP.MP.120	Pediatric Liver Transplant	Apple Health, Ambetter	Revised	11/1/2026
	CP.MP.129	Fetal Surgery in Utero for Prenatally Diagnosed Malformations	Apple Health, Ambetter	Revised	11/1/2026
	CP.MP.185	Skin Substitutes for Chronic Wounds	Apple Health	Revised	11/1/2026
X	CP.MP.202	Orthognathic Surgery	Apple Health, Ambetter	Revised	11/1/2026
X	CP.MP.31	Cosmetic and Reconstructive Procedures	Apple Health, Ambetter	Revised	11/1/2026
	CP.MP.49	Physical, Occupational and Speech Therapy Services	Apple Health, Ambetter	Revised	11/1/2026
	CP.MP.54	Hospice Services	Ambetter	Revised	11/1/2026
X	CP.MP.62	Hyperhidrosis treatments	Apple Health, Ambetter	Revised	11/1/2026
X	CP.MP.91	Obstetrical Home Health Care Programs	Ambetter	Revised	11/1/2026
X	HIM.CP.MP.395	Coverage for Gender Affirming Procedures	Ambetter	Revised	11/1/2026
	WA.CP.MP.248	Sleep Apnea Diagnosis and Treatment	Apple Health	Revised	11/1/2026
X	WA.CP.MP.500	Mandibular Advancement Devices	Apple Health	Revised	11/1/2026
X	WA.CP.MP.70	Proton and Neutron Beam Therapies	Apple Health	Revised	11/1/2026
	CP.BH.104	Applied Behavior Analysis Therapy	Ambetter	Revised	1/1/2027
	CP.MP.133	Posterior Tibial Nerve Stimulation for Voiding Dysfunction	Ambetter	Revised	1/1/2027
	CP.MP.86	Neonatal abstinence syndrome guidelines	Apple Health, Ambetter	Revised	1/1/2027
	WA.CP.MP.54	Hospice Services	Apple Health	Revised	1/1/2027
X	CP.MP.107	Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines	Apple Health, Ambetter	Revised	2/1/2027
X	CP.MP.249	Omisirge (omidubicel): Nicotinamide-modified allogeneic hematopoietic progenitor cell therapy	Apple Health, Ambetter	Revised	2/1/2027
X	CP.MP.182	Short Inpatient Hospital Stay	Apple Health, Ambetter	Retired	11/1/2026
X	CC.PP.182	Short Inpatient Hospital Stay	Apple Health, Ambetter	New	11/1/2026

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Pharmacy

Pharmacy Updates

Gender Affirming Care Drugs- Non-Contracted Effective 10/13/2026 for members 18 years of age and younger.

A new federal regulation prohibits states from using federal Medicaid funds to cover certain gender-affirming care services for minors, referred to as “sex-rejecting procedures.” Effective October 13, 2026, certain drugs associated with gender-affirming care, regardless of diagnosis, for members 18 years of age or younger must be billed through fee-for-service.

Pharmacies have been notified to bill fee-for-service for drugs affected by this federal rule. Pharmacies should refer to HCA’s fax broadcast and the following:

Pharmacy Clinical Policies

The following pharmacy policies have been updated. Updated policies will be posted to the policy site.

A summary of the revisions is available in the policy revision log at the end of the policy.

Policy Number	Policy Title	Effective Date	Line of Business	Change
CP.PHAR.524	Pegcetacoplan (Empaveli, Syfovre)	10/01/2026	Ambetter	Updated
CP.PHAR.565	Asciminib (Scemblix)	10/01/2026	Ambetter	Updated
CP.PHAR.582	Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto)	10/01/2026	Ambetter	Updated
CP.PHAR.674	Marstacimab-hncq (Hympavzi)	10/01/2026	Ambetter	Updated
CP.PHAR.720	Nipocalimab-aahu (Imaavy)	10/01/2026	Ambetter	Updated
CP.PMN.295	Semaglutide (Wegovy)	10/01/2026	Ambetter	Updated
CP.PMN.298	Tirzepatide (Zepbound)	10/01/2026	Ambetter	Updated
HIM.PA.53	Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists	10/01/2026	Ambetter	Updated
CP.PHAR.105	Bosutinib (Bosulif)	11/01/2026	Ambetter	Updated
CP.PHAR.111	Cabozantinib (Cabometyx, Cometriq, Omcazio)	11/01/2026	Ambetter	Updated
CP.PHAR.112	Ponatinib (Iclusig)	11/01/2026	Ambetter	Updated
CP.PHAR.570	Ropeginterferon Alfa-2b-njft (BESREMi)	11/01/2026	Ambetter	Updated
CP.PHAR.622	Lenacapavir (Sunlenca, Yeztugo)	11/01/2026	Ambetter	Updated
CP.PHAR.764	Sevabertinib (Hyrnuo)	11/01/2026	Ambetter	Updated
CP.PHAR.778	Garetosmab-grts (Pasatru)	11/01/2026	Ambetter	Updated
HIM.PA.53	Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists	11/01/2026	Ambetter	Updated
CP.PHAR.232	OnabotulinumtoxinA (Botox)	10/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.260	Rituximab (Rituxan), Rituximab-abbs (Truxima), Rituximab-arrx (Riabni), Rituximab-cdxx (Zimrixby), Rituximab-pvvr (Ruxience), Rituximab/Hyaluronidase (Rituxan Hycela)	10/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.568	Inclisiran (Leqvio)	10/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.605	Adagrasib (Krazati)	10/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.768	Lerodalcibep-liga (Lerochol)	10/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.774	Vusolimogene Oderparepvec-wtpg (Tudriqev)	10/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.794	Daraxonrasib (Rasonque)	10/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.236	Darbepoetin Alfa (Aranesp)	11/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.237	Epoetin Alfa (Epogen, Procrit), Epoetin Alfa-epbx (Retacrit)	11/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.414	Larotrectinib (Vitrakvi)	11/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.479	Decitabine/Cedazuridine (Inqovi)	11/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.493	Infusion Therapy Site of Care Optimization	11/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.687	Tislelizumab-jsgr (Tevimbra)	11/01/2026	Ambetter & Medicaid	Updated
CP.PHAR.709	Zanidatamab-hrii (Ziihera)	11/01/2026	Ambetter & Medicaid	Updated

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Wellcare

Visit the Wellcare provider resources page for the latest updates including Medical Clinic policies.

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Apple Health Core Connections

November is National Adoption Month!

Youth adopted from foster care in Washington may be covered by Coordinated Care’s Apple Health Core Connections health plan. AHCC’s care management team have received National Adoption Competency Mental Health training and are prepared to support the needs of our adopted members. Providers can access this training here.

Coordinated Care facilitates a no-cost caregiver support group via Zoom that is open to all adoptive, foster, kinship and guardianship caregivers that need support, resources and to meet others that may have similar experiences. There is no registration necessary. For further information contact: Zia.Freeman@CoordinatedCareHealth.com It occurs at 6pm on the 2^nd and 4^th Thurs of each month. Use this link to attend.

Coordinated Care also sponsors free one-on-one and group virtual mentoring for adoptees ages 12-17 for any youth adopted from foster care in Washington through our partnership with Adoptee Mentoring Society. Members can email info@adopteementorship.org to receive a scheduling code to book sessions at no cost. Learn more about Adoptee Mentoring Society here.

Coordinated Care is the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program in collaboration with the Washington State Health Care Authority and Washington State Department of Children, Youth and Families. Our program, Apple Health Core Connections, serves children and youth in foster care, adoption support, alumni of foster care (ages 18-26), children reunified with their parents, and youth in the Unaccompanied Refugee Minor program.

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Training/Education

Promoting Understanding and Healing in Adoption and Foster Care
November 5^th from 7:00am-9:00am PST

This course provides an opportunity to learn about the Seven Core Issues that impact the lives of birth family, foster family, adoptive family, and other constellation members. The Seven Core Issues are Loss, Rejection, Shame/Guilt, Grief, Identity, Intimacy, and Master and Control. The impact of trauma and attachment are discussed. Register online here.

Trauma Informed Interventions: Supporting Healthy Behaviors in Trauma Exposed Youth
November 10^th from 8:00am-10:30pm PST

In this training, attendees will learn how to more effectively support trauma exposed youth by using trauma informed de-escalation techniques. This course provides a robust examination of trauma and how trauma reminders impact youth behaviors. Register online here.

Maintaining a Healthy Professional Life: The Science Behind Self-Care
November 18^th from 7:00am-8:30am PST
Research shows that helping professionals are at high risk of being affected by the negative aspects of daily activities that entail working closely with individuals presenting with psychological distress and/or suffering. This training explains the positive and negative aspects of helping members who experience trauma and suffering and ways a helping professional can decrease their risks of burnout, and compassion fatigue. Register online here.

That Makes Sensory: Understanding Sensory Processing Differences in Children
December 7^th from 9:00am-11:00am PST

This training will give parents and professionals a deeper understanding of what sensory processing is, its’ importance, and what it means when a child has a dysfunctional sensory system. Participants will learn the basics about the sensory motor loop, the eight senses in sensory processing, the different types of dysfunction, and how a dysfunctional sensory system impacts children’s roles and routines both at home and in school. Register online here.

TIC: Understand & Reduce Traumatic Reactions in youth
Nov 12, 01:00 – 03:00pm

Children who have experienced trauma often bring challenging behaviors to their environment. Professionals and caregivers may not know what to do, which can lead to frustration, detachment, and even placement disruption. This training offers a Trauma refresher overview and ideas into helping the child manage their reactions and behaviors. Developed by the National Child Traumatic Stress Network (NCTSN).

Coping with Holiday Stress with Youth
Nov 18, 2026 11:30am – 01:30pm

All of us can feel stressed around the holidays. This stress can be amplified by feelings of grief and loss for youth in foster care, kinship, and early adoption. This training will help participants identify holiday concerns that children in new homes feel, create a healthy environment for the holidays, and how to help youth, caregivers, & professionals cope.