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[Georgia] Medical Policies and Clinical Utilization Management Guidelines update

Anthem BCBS·GA · Dermatology, Plastic Surgery, Physical Therapy +13 more·Prior Authorization
Effective date
May 14, 2026
We identified it
May 18, 2026
Days to comply
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Summary

Anthem Georgia updated multiple medical policies and clinical utilization management guidelines effective May 14, 2026, including revisions to prior authorization requirements, coverage criteria, and medical necessity standards for services such as gene therapy, surgical procedures, durable medical equipment, and diagnostic testing. Some previously covered services may now be found not medically necessary under the revised criteria.

Action Required

Action needed
By May 14, 2026: Billing team must obtain and review all revised Medical Policies (ANC.00007, DME.00011, LAB.00019, MED.00129, MED.00161, SURG.00129, TRANS.00009) and Clinical UM Guidelines (CG-ANC-04, CG-DME-24, CG-DME-33, CG-DME-34, CG-DME-37, CG-LAB-36, CG-MED-103, CG-MED-104, CG-MED-105, CG-MED-26, CG-SURG-130, CG-SURG-83) from Anthem's Medical Policies & Clinical UM Guidelines website. Update all prior authorization workflows, claim submission processes, and encounter documentation templates to reflect new medical necessity criteria. Train all clinical and billing staff on coverage changes, particularly for cosmetic/reconstructive services, gene therapy, sleep apnea surgery, transplantation, mobility devices, hearing aids, bariatric surgery, and assisted reproductive technology. Before May 14, 2026: Communicate policy changes to all providers and clinical staff via the Anthem Georgia provider newsletter. Flag all affected service lines in billing software to ensure claims are processed according to new criteria. Failure to implement updated requirements will result in claim denials and potential compliance violations. Contact Anthem at https://providernews.anthem.com/georgia/ or reference publication MULTI-BCBS-CR-008203-26-GRP1935 for complete policy details.

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