PA Reform Goes Big: UHC Cuts 30% of Prior Auths — and Isn't Alone
A busy month across payers, led by the largest prior authorization rollback in UHC's history and a new BCBS NC documentation requirement with real bite.
Uptick Intelligence · Brief 01
UnitedHealthcare
UHC Medicare Advantage HMO Referral Requirement — Grace Period Extended
UnitedHealthcare has extended its grace period on adverse payment decisions related to PCP referral requirements for Medicare Advantage HMO plans. The previous grace period was set to expire April 30, 2026, but UHC has confirmed it will continue to defer adverse actions while it shares additional details with providers. No new end date has been announced yet — UHC has stated advance notice will be given before the grace period closes.
As background: most UHC Medicare Advantage HMO plans require a primary care physician referral for specialty services. During the grace period, UHC has not been issuing payment denials when that referral is absent. When the grace period ends, claims for specialty visits without a valid PCP referral on file will be subject to denial.
Practices that see UHC Medicare Advantage HMO patients for specialist visits should confirm their referral intake workflows are solid before this grace period closes. Uptick will monitor for the updated end date and communicate as soon as it is published.
UHC Eliminates Prior Authorization for 30% of Services by Year-End
UnitedHealthcare announced on May 5, 2026, that it will eliminate prior authorization requirements for an additional 30% of services that previously required insurer approval — to be completed by the end of 2026. Affected services include select outpatient surgeries, diagnostic tests such as echocardiograms, and certain outpatient therapies. The full list of affected codes will be published on UHCprovider.com before changes take effect.
This follows UHC's 2023 reduction of roughly 20%, meaning the cumulative effect is substantial. UHC also notes that prior authorization is currently required for only 2% of medical services, and approximately 92% of submitted requests are already approved within 24 hours. The announcement is directly relevant for orthopaedics practices, where many diagnostic and outpatient surgical services have historically required auth.
Uptick Intelligence · Brief 02
BCBS NC
BCBS NC: Year-Round HEDIS Medical Record Reviews Begin 2026
Published May 7, 2026, BCBS NC has announced it is implementing a year-round medical record review (MRR) process for select HEDIS measures in 2026, rather than conducting a single concentrated review period. This aligns with NCQA's multi-year push toward fully digital quality measurement by 2030, which includes phasing out hybrid reporting by 2029 in favor of Electronic Clinical Data Systems (ECDS) and full-population administrative data.
Practically, this means BCBS NC will be reaching out to provider offices and HIM departments throughout the year to request medical records for members with identified care gaps. The intent is continuous care gap closure, not a once-a-year scramble. Existing retrieval contacts and workflows will be used wherever possible to reduce administrative burden.
For Uptick clients: Accurate, timely claims coding is the most important thing providers can do to support this process. Closing care gaps through HEDIS compliance also benefits practices in value-based or incentive programs attributed to BCBS NC members.
BCBS NC Medicare Advantage: New Step Therapy and PA Requirements for Select Part B Drugs
Effective April 6, 2026, Blue Cross NC expanded step therapy and prior authorization requirements for select Medicare Part B medications. Two categories of requirements apply.
Prior authorization required (new): Biosimilars Osenvelt and Stoboclo (Q5157), Wyost (Q5136), and biosimilars Bilprevda and Bildyos (Q5162) now require PA before administration for Medicare Advantage members.
Step therapy required (new, applies to members new to these drugs only): Xgeva and Prolia (J0897), Bomyntra and Conexxence (Q5158), Xtrenbo and Enoby (J3490/J3590), Aukelso and Bosaya (Q5161), Ospomyv and Xbryk (Q5159), and Imaavy (J9256). Patients already on these medications are not affected.
Submitting claims without prior authorization for PA-required drugs means Blue Cross NC may not cover the service, and the provider may be responsible for the full drug cost. Providers cannot bill members when PA was required but not obtained. PA requests must be submitted electronically through CoverMyMeds. Pharmacy drug requests can also go through MHK via Blue e.
Uptick Intelligence · Brief 03
Anthem BCBS
Anthem BCBS: Correct Use of JW and JZ Modifiers Required for Drug Waste Billing
Anthem BCBS has issued a reminder that its Pharmaceutical Waste reimbursement policy (C-11031) requires correct use of the JW and JZ modifiers on professional claims involving single-dose vial drugs. This is consistent with CMS requirements that have been in effect since 2023, but Anthem is actively enhancing its claims review process to enforce compliance across all states.
When waste occurs (drug left in single-dose vial after administration): Submit two claim lines for the HCPCS/drug code. Line 1: units administered, no modifier. Line 2: units discarded, append JW modifier.
When no waste occurs (full vial administered): Submit one claim line with the JZ modifier to attest no drug was discarded.
Claims that do not correctly include JW or JZ where required may be returned as unprocessable or subject to audit. This is particularly relevant for dermatology (injectable biologics, neuromodulators), ophthalmology (anti-VEGF injections such as Eylea or Lucentis), and any practice billing incident-to injectable drugs from single-dose containers.
Uptick Intelligence · Brief 04
NC Medicaid
H.R. 1 Medicaid Work Requirements: NC Faces January 2027 Deadline
North Carolina is actively preparing for the implementation of Medicaid work requirements mandated by the One Big Beautiful Bill Act (H.R. 1, signed July 4, 2025). The law requires non-exempt Medicaid expansion enrollees (adults ages 19–64 without disabilities) to document 80 hours per month of work, job training, volunteering, or education to maintain coverage. States must implement by January 1, 2027.
Federal implementation guidance from HHS is due by June 1, 2026, and state outreach to impacted NC Medicaid members must begin between June 30 and August 31, 2026. NC Medicaid leadership has publicly acknowledged the implementation timeline is "very tight." Coverage interruptions for non-compliant or administratively lost enrollees are expected to begin in 2027.
Practical concern for your practice: Patients in the Medicaid expansion population who do not complete outreach or paperwork could lose coverage mid-care. This has direct impact on scheduling, pre-authorization workflows, and eligibility verification. Uptick will flag coverage gaps at eligibility check, but front desk staff should be attentive to coverage changes for patients who are in the NC Medicaid expansion population beginning in late 2026.
| Payer | Network | Coding | Billing |
|---|---|---|---|
| UHC | |||
| BCBS NC | |||
| Anthem BCBS | |||
| NC Medicaid |
Circulate this resource
Brief your revenue cycle team.
Share the practical guidance, source links, and staff actions with the practice leaders responsible for implementation.
Monthly payer intelligence
Keep payer changes on your operating radar.
Subscribe for a concise monthly briefing on policy changes that affect claims, authorizations, documentation, and staff workflows.
Unsubscribe any time. We respect your inbox.