Pay BillSCOPE | Provider Update
July 2026
Clinical Matters
Advancing Prevention: A practical guide to the 2026 ACS Colorectal Cancer Screening Update
The American Cancer Society (ACS) released updated colorectal cancer (CRC) screening guidelines on May 27, 2026, reinforcing the central role of prevention in primary care while introducing new tools to improve screening uptake and outcomes.
Colorectal cancer remains a leading cause of cancer-related death in the United States, with increasing incidence among adults under 50. At the same time, about one-third of eligible adults remain unscreened, representing a major gap in preventive care.
Primary care providers (PCPs) are uniquely positioned to close this gap by identifying eligible patients early, offering appropriate screening options, and ensuring timely follow-up after abnormal results.
What remains the same: core framework
The 2026 update reaffirms the existing screening structure, meaning your current workflows are likely to still apply:
- Start screening at age 45
- Continue through age 75 (if life expectancy greater than 10 years)
- Individualize screening for ages 76 to 85
- For ages older than 85: Do not screen (droracle.ai; labtestsguide.com)
Acceptable screening options include stool-based tests, annual FIT or high-sensitivity gFOBT, as well as stool DNE or RNA testing every three years. In addition, the structural exams remain: colonoscopy every 10 years or the CT colonography or flexible sigmoidoscopy every five years.
What's new and why it matters
The biggest change is not who to screen—but how to get more patients screened.
Expanded screening options
The guideline adds newer, more accessible tests:
- Next-generation stool DNA testing
- New stool RNA-based testing
- Blood-based (ctDNA) testing
Blood-based testing: use carefully
- Included as an option—but not preferred. Best for patients who decline stool testing or the colonoscopy.
- Limitation: lower sensitivity for early cancer and precancerous lesions
Key shift: focus on completion
The most important takeaway for PCPs is a shift in philosophy: “The most effective screening test is the one the patient completes.” This reflects a move toward patient-centered care, reducing barriers, and improving real-world adherence.
What this means for primary care practices
- Offer options: Colonoscopy remains the gold standard, especially for “At Risk patients.” In practice with “Average Risk” patients, it’s important to use shared decision-making, and normalize their choices, such as asking them “would you prefer a home test or a colonoscopy?” Many patients are more likely to complete stool-based tests and at-home options.
- Prioritize completion over test type: A completed FIT is more valuable than an uncompleted colonoscopy referral. Focus on getting the test done and reducing friction (cost, time, prep concerns).
- Close the loop every time: Screening is not complete without follow-up. All positive tests should lead to a colonoscopy. Try to ensure timely referral and completion of the test, as delays reduce benefit and increase risk.
Impact on Quality Metrics and Outcomes
The updated guideline aligns closely with value-based care and quality measures:
- Improve Screening Rates (HEDIS)
- CRC screening = core quality metric
- Offering options results in higher completion rates
- Reduce Disparities: At-home tests improve access for rural populations and underserved groups
- Improve Outcomes. Early detection can lead to a 5-year survival rate of 90%, reducing advanced cancer diagnoses, mortality, and lowers treatment costs.
Bottom line
The 2026 ACS update represents a shift toward flexible, patient-centered screening. The biggest impact is not choosing the “best” test. It is ensuring that more patients complete screening and receive appropriate follow-up.
Sources available on request.
A Primary Care approach to the 2026 ACC Dyslipidemia Guideline: from cholesterol management to CKM prevention
The 2026 ACC/AHA multi-society guideline on the management of dyslipidemia represents a major evolution in cardiovascular prevention. Prior guidelines, most notably the 2018 cholesterol guideline, focused heavily on statin intensity and risk thresholds. The 2026 update shifts toward earlier, more personalized, and lifetime-based risk reduction.
For primary care providers (PCPs), this is less about learning entirely new treatments and more about changing how and when to intervene to reduce atherosclerotic cardiovascular disease (ASCVD) risk.
Why this update matters
Cardiovascular disease remains the leading cause of death globally, and dyslipidemia is a central, modifiable driver. The updated guideline reinforces that ASCVD risk is driven by cumulative exposure to atherogenic lipoproteins over time, not just a snapshot LDL level.
At the same time, real-world care gaps persist, due to an underuse of statins, delayed treatment, and inadequate long-term adherence. That is why it is important for primary care to be at the frontline for addressing these gaps.
What has changed from the 2018 guideline
1. Return of LDL-C Treatment Goals: The 2018 guideline emphasized statin intensity; the 2026 update reintroduces clear LDL-C targets, providing more concrete treatment endpoints and clearer intensification pathways:
- Primary prevention: less than 100 mg/dL
- High-risk: less than 70 mg/dL
- Very high-risk (secondary prevention): less than 55 mg/dL
2. Earlier and more aggressive interventions: The new guideline emphasizes treating earlier in life, shifting from reactive to preventive cardiology. Consider therapy in:
- Young adults with LDL equal to or greater than 160 mg/dL
- Strong family history of premature ASCVD
- Reducing lifetime exposure to LDL-C
3. New Risk Assessment Model (PREVENT): The PREVENT risk equations - Predicting Risk of Cardiovascular Disease Events - are now incorporated into newer ACC/AHA guidance (including dyslipidemia and emerging hypertension frameworks).
- Replaces the Pooled Cohort Equations (PCE)
- Incorporates broader and more contemporary risk factors
- Estimates both 10-year and 30-year risk
Unlike prior tools, PREVENT emphasizes lifetime and holistic cardiometabolic risk, aligning more closely with the modern cardiovascular–kidney–metabolic (CKM) prevention model.
PCP implication:
- Start risk assessment earlier (age 30 and older)
- Use a lifetime risk perspective, not just 10-year risk
4. Expanded role of biomarkers and imaging. There is a new emphasis on:
- Lipoprotein(a) (Lp[a]) – measure at least once
- Apolipoprotein B (ApoB) for residual risk
- Coronary artery calcium (CAC) to refine decisions
These tools help clarify borderline risk and guide therapy escalation.
5. Broader Therapeutic Options: In addition to statins, the update recommends expanded access and earlier use of the following agents in appropriate patients:
- Ezetimibe
- PCSK9 inhibitors
- Inclisiran
- Bempedoic acid
Key Paradigm Shift: “Lower Earlier, Lower Longer”
The central message of the 2026 guideline is “Earlier and sustained LDL-C reduction leads to greater lifetime cardiovascular protection.” This reframes dyslipidemia management as a life-course disease model, not episodic care, and a continuous opportunity for prevention.
Connecting to Cardiovascular–Kidney–Metabolic (CKM) Syndrome
The release of the dyslipidemia guideline aligns closely with the 2026 CKM syndrome guideline, which highlights the interconnected nature of cardiovascular disease with chronic kidney disease and metabolic disease (e.g., obesity and diabetes).
CKM syndrome emphasizes that these conditions do not occur in isolation, and that dyslipidemia is a core contributor of CKM syndrome across all stages.
Dyslipidemia management is now part of a broader strategy to prevent multisystem disease progression and address lipids, blood pressure, glycemia, weight, and kidney function, which supports a shift from disease-specific care to integrated cardiometabolic care.
Impact on Outcomes and Quality Measures
- Improved Cardiovascular Outcomes:
- Earlier LDL reduction leads to lower ASCVD events
- Addresses lifetime risk, not just short-term risk
- Alignment With Value-Based Care: improves performance on HEDIS lipid management measures; ASCVD risk reduction metrics, and diabetes and CKD quality measures.
- Population Health Impact. Earlier intervention reduces cardiac arrest and stroke, CKD progression and heart failure risk.
Practical Implementation: Action Steps for PCPs: Start risk discussions at age 30, and check lipid panels routinely and earlier. Stratify risk by using the PREVENT calculator, and consider CAC when uncertain.
- Treatment:
- Initiate statins earlier when appropriate
- Treat to LDL-C targets
- Escalate therapy if goals not achieved
- Care coordination: Address CKM risks together (lipids, diabetes, kidney disease)
Bottom Line
The 2026 ACC dyslipidemia guideline represents a shift toward proactive, lifetime cardiovascular prevention. The biggest opportunity is not just lowering LDL today. It is reducing cumulative cardiovascular risk across the patient’s lifetime.
Sources available on request.
Office Matters
New NCD and LCD Medicare claim edits begin August 1, 2026
Independent Health will activate seventeen new claim edits sourced from National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) for our Medicare members' claims for dates of service on and after August 1, 2026. Please refer to the list below of NCD and LCD policies.
As a reminder, the “Coding Adherence to Medicare LCDs and NCDs” section of the Participating Provider Reimbursement Manual contains additional information on these edits and includes a comprehensive list of LCDs and NCDs that are used to source the new claim edits.
Code |
Description |
|---|---|
20.19 |
|
210.14 |
|
210.2 |
|
210.4.1 |
|
L33567 |
|
L33574 |
|
L33616 |
|
L33619 |
|
L33621 |
|
L33626 |
|
L33627 |
|
L33630 |
|
L33632 |
|
L34380 |
|
L35098 |
|
L39036 |
|
L40048 |
Mandatory annual training: Independent Health’s Assure Advantage (HMO-SNP) 2026 Model of Care
Independent Health is committed to ensuring its provider network meets all regulatory requirements set forth by the Centers for Medicare & Medicaid Services (CMS) as mandated by 42 CFR§422.101(f)(2)(ii).
It is time for provider staff who see Independent Health Assure Advantage Medicare members on a routine basis to complete the 2026 Annual Model of Care Provider training by August 31, 2026.
Assure Advantage is a Chronic Special Needs Plan (C-SNP), designed for eligible Medicare beneficiaries who have been diagnosed with chronic heart failure and reside in Erie County.
Who must complete the training?
All provider staff who see Medicare patients on a routine basis must complete the training, including care coordination staff, administrative staff, or other clinical or support staff.
How does your practice complete this training?
The 2026 Annual Model of Care Provider Training is conducted online following these steps:
View and/or download the presentation here.
Once your practice/staff have completed the training module, fill out the attestation that accompanies the training presentation or click here to start attestation. Only one attestation per practice is required.
Please complete the attestation by August 31, 2026.
If you have any questions, please contact Provider Relations Monday through Friday from 8 a.m. to 5 p.m. at (716) 631-3282.
Guidelines for non-covered cosmetic services
Outlined below are guidelines for our participating providers and members to follow in the instances when members choose to have non-covered cosmetic procedures performed. The guidelines vary by line of business. Please make sure you review this important information.
Commercial and State-sponsored products
When a cosmetic procedure is determined to be non-covered under Commercial or State plans, providers must adhere to the following requirements:
- The provider must clearly inform the member that the requested service is not covered under their benefit plan.
- If the member elects to proceed with the service, it must be treated as a self-pay arrangement.
- Prior to rendering services, the provider is required to obtain a written agreement that includes:
- A detailed description of the specific service or procedure
- The applicable CPT and/or HCPCS codes
- The total anticipated charges for the services
- A clear statement indicating that the service is the financial responsibility of the member
- The member must review and sign the agreement acknowledging financial responsibility before the service is performed.
- A record of the agreement must be kept within the member’s account
- Claims should not be submitted for non-covered cosmetic services under Commercial or State plans.
Medicare products
For cosmetic procedures that may be considered non-covered under Medicare:
- The provider should submit a Pre-Service Coverage Determination for review fax (716) 635-3910
- The request must be prominently labeled at the top with the designation: “Organization Determination/NDMC Request.
This process ensures that a formal coverage determination is made prior to the delivery of service, the member is notified by Independent Health and allows the provider to bill the member.
Important Considerations
- Accurate documentation and proper member acknowledgment are essential to ensure regulatory compliance and to mitigate the risk of billing disputes or member grievances.
- Providers are responsible for maintaining the signed agreement as part of the member’s medical and financial record.
Monthly Update: Upcoming member engagement campaigns to encourage members to take greater control of their health
Independent Health develops outreach campaigns to members in need of certain preventive services and to help make them aware of our programs and resources to help them maintain or improve their health. Here is a summary of the current outreach campaigns underway.
Preventive Cancer Screening Campaign
This campaign provides education on the importance of preventive cancer screenings and encourages Medicare and State Products members to complete a breast cancer and/or colorectal cancer screening where open gaps exist.
- Target population: Medicare and State Products members whose providers are not part of an IPA (Individual Practice Association)
- Outreach method: Outbound telephone call campaign
- Launch Date: Telephonic outreach will begin in late July and run through August
State Program Member Incentive Campaigns
Independent Health State Program members will have until December 31, 2026, to complete various preventive care visits and screenings to receive an incentive for the following programs:
- Gap in Care Program - State members can earn gift cards for completing various preventive care tests and screenings.
- Non-Utilizer Program - State program members with 7 or more months of continuous enrollment without a claim on file are eligible to earn a gift card for completing an annual well visit.
- Maternity Management Program - State program members can earn gift cards for completing a prenatal visit during the first 12 weeks of pregnancy and postpartum visit within 11 weeks after delivery.
- Launch Date: May through December
Falls Prevention Campaign
This campaign targets Medicare members identified as having a high likelihood of falling or history of falls to provide fall prevention education and encourage members to speak to their doctor about ways to prevent falls.
- Target population: Medicare members who have a high likelihood of falling or a history of falls.
- Outreach method: Outbound telephone call and email campaign.
- Launch Date: Telephonic outreach began in late April; Email campaign began in May and will continue through July.
Physical Activity Campaign
This campaign targets Medicare members identified as having low physical activity levels to provide education regarding the benefits of physical activity and encourages members to speak to their doctor about ways to be more active.
- Target population: Medicare members who have low physical activity levels.
- Outreach method: Outbound telephone call and email campaign.
- Launch Date: Telephonic outreach began in late April; Email campaign is occurring between May through July.
Bladder Control Campaign
This campaign targets Medicare members identified as having urinary incontinence and encourages them to speak to their PCP regarding urinary incontinence and potential solutions.
- Target population: Medicare members who self-identify as having urinary incontinence.
- Outreach method: Outbound telephone call and email campaign.
- Launch Date: Telephonic outreach began in late April; Email campaign is occurring between May through July.
Physical and Mental Health Campaign
This campaign targets Medicare members identified as having concerns with their physical or mental health to provide education regarding who to contact about any physical and mental health concerns and encourages them to speak to their doctor about these concerns.
- Target population: Medicare members who are identified as having concerns with their physical or mental health.
- Outreach method: Outbound telephone call and email campaign.
- Launch Date: Telephonic outreach began in late April; Email campaign is occurring between May through July.
Health-Related Social Needs Self Screening
This campaign will encourage members to complete a health-related social needs screening, and we will provide referral information for community resources if an area of need is identified.
- Target Population: MediSource Connect (HARP); Essential Plan, Commercial, Mainstream Medicaid subpopulation.
- Outreach Method: Telephonic and email campaigns
- Timeframe: January through December 2026
Osteoporosis Management in Women Who Had a Fracture (OMW) Member Outreach
Independent Health’s Medication Therapy Management (MTM) Pharmacy Team will outreach telephonically to Medicare members who fall into the Osteoporosis Management in Women Who Had a Fracture (OMW) measure. The MTM Pharmacy Team will contact members to provide education on the importance of getting screened for osteoporosis following a fracture, discuss any clinical and medication concerns as well as options for gap closure.
The option of an in-home heel ultrasound with Stall Senior Medical (SSM) will be discussed. If the member is interested, The MTM Pharmacy Team will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment.
All results will be sent to the member’s Primary Care Physician (PCP) for follow-up. The MTM Pharmacy Team will also discuss other options for gap closure, depending on the member’s preference, and refer back to the member’s PCP. Each call will be individualized based on the member’s needs.
Annual Cultural Competency and FWA attestation
Independent Health is required by state and federal agencies to ensure our participating providers complete this annual compliance training.
All participating practices must attest they have completed each of the following by December 31, 2026:
- Cultural Competency Training: All providers who treat Independent Health’s Commercial and State program members must attest annually that they have completed cultural competency training for all staff who have regular and substantial contact with our members.
Please use the Think Cultural Health training guide. The guide offers two modules: one tailored for health care administrators and the other for health care providers or those providing direct care and services. (Note: although the website indicates that the content is under review for updates, practices may use it to complete the requirements).
- Fraud, Waste & Abuse Training: If you haven’t done so already for 2026, provider groups or practices must complete Fraud, Waste & Abuse (FWA) Training and submit an electronic attestation to confirm each of their staff members have completed this training.
Staff members required to complete this training include physicians, mid-levels, ancillary providers, registered nurses, licensed practical nurses, administrative and office staff, technicians, coders and others.
Who must submit each attestation?
An authorized representative must submit each of the above attestations on behalf of all individuals under a practice’s Tax Identification Number (TIN). Therefore, each individual staff member who completes each training does not need to submit the attestation.
Home Care Registry IDs to be required on claims beginning with dates of service of Oct. 1, 2026
As of October 1, 2026, New York State’s Office of Health Insurance Programs (OHIP) will require claims for Home Health Care provided by LHCSAs and CHHAs – as well as managed care organizations and the Consumer Directed Personal Assistance Services (CDPAS) – to submit provider information for Direct Care Workers.
Medicaid Home Health Aide, Personal Care, and CDPAS claims submitted to Independent Health must include Direct Care Worker information in the rendering provider loops detailed in this letter from the NYSDOH beginning with the October 1, 2026, date of service.
Direct Care Workers will be identified using Home Care Registry IDs for all Home Health Aide and Personal Care encounters and using SFI Personal Assistant IDs for all CDPAS encounters.
For full details, please download and read the following:
Please ensure you work with your EDI clearinghouse or billing agency well in advance to be prepared for the October 1 requirement.
We are sharing this important update on behalf of New York State. If you have any questions regarding this guidance, contact ManagedCareEncounterCompliance@health.ny.us.
Pharmacy Updates
Medicare GLP-1 Bridge Program launches July 1, 2026
The Centers for Medicare and Medicaid Services (CMS) will launch the GLP-1 Bridge on July 1, 2026. This federal pilot program is designed to increase access to certain GLP-1s for Medicare Part D beneficiaries who seek the drug solely for weight loss or weight maintenance.
These individuals would not be eligible to receive a GLP-1 drug through their plan’s Part D benefits. The Bridge program is slated to end 12/31/2027.
GLP-1 Bridge Summary
The CMS Bridge program covers specific GLP-1 drugs only when used for weight loss and not for any other approved indication.
- Foundayo (tablets), Wegovy (oral and injectable), and Zepbound Kwikpen are covered by the program for those who qualify.
- The beneficiary must not have type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease.
- There are also other criteria used to determine eligibility.
If a beneficiary is approved for access to a GLP-1 drug through the Bridge program, their cost for a 30-day supply will be $50.
Providers and pharmacies are not required to obtain a claim denial from us before submitting a claim to the GLP-1 Bridge program.
Where to Find More Information
CMS has conducted outreach to support providers, pharmacies, and plans in preparing for this program. Please refer to the dedicated CMS webpage for provider-specific guidance and program details.
If a patient has questions about the program, they should call 1-800-MEDICARE.
Our GLP-1 drug policies will not change on July 1, 2026. This is a CMS program.
Faster and easier submission of Medicare Part D vaccine claims
Independent Health has partnered with TransactRx to offer a more efficient, online solution for submitting Part D vaccine claims for Medicare members with Part D coverage.
This streamlined process eliminates the need for paper claims and removes the burden of asking Medicare patients to pay out-of-pocket costs upfront before seeking reimbursement.
TransactRx is a web-based tool that offers:
- Easy online access to patient specific coverage
- Electronic claims submission and faster reimbursements for vaccines covered under Part D
- Real-time out-of-pocket (copay) cost and reimbursement information
- Reduced administrative burden
How to get started
There is no cost to enroll, and getting started is quick and straightforward. The process requires minimal onboarding, allowing providers to begin submitting claims within just a few days.
- New user? Visit transactrx.com/enrollment
- Existing users can simply log in at mytransactrx.com. You can process claims for Independent Health Medicare members just like any other Part D patient you currently bill through the system.
- Unsure if you have an account? Contact TransactRx at 1-866-522-3386.
Formulary and Policy Changes
Remember to view our up-to-date policies online.
Drug Formulary Changes
View the formulary deletions, effective July 1, 2026:
- Medicare Advantage formulary deletions for the Individual Standard formulary
- Medicare Advantage formulary deletions for the Individual Enhanced & Group formularies
- Pharmacy Benefit Dimensions 3-Tier formulary deletions
- Pharmacy Benefit Dimensions 5-Tier formulary deletions
Access Independent Health's drug formularies here.
Drug Policy Changes
Search for and view the most current versions of all Independent Health’s drug policies when logged in to our provider portal.
Prime Therapeutics reviews prior authorizations for select oncology and specialty drugs on Independent Health’s behalf. Log in to view Prime Therapeutics policies for the drugs it reviews.
To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 5 p.m.
In the News
The premium dollar: where does your healthcare dollar go? (Healthy Vision blog)
Spotlight
Top Takeaways this Month
Monthly Policy Updates: View them here (Posted as Monthly Policy Updates under the News tab in the secure portal). It is very important to review the monthly updates.
Provider Data Survey Reminder: Please review and return your provider data surveys that we send quarterly. Your responses ensure your information in our online Find-A-Doc tool our members rely on is accurate and up to date.
Closed provider panels: A network assessment has determined that our network for Licensed Clinical Social Workers (LCSW) and Licensed Mental Health Counselors (LMHC) is adequate to meet the needs of our members. Therefore, we will not accept applications for new groups of LCSWs and LMHCs as of July 1, 2026.. Check here for ongoing updates.
Don't forget: Fraud, Waste & Abuse Mandatory Training and Attestation! Learn more and complete this requirement here.