Medicare AdvantagePrior AuthMedium impact
[Virginia] Carelon Medical Benefits Management, Inc. code updates
Anthem BCBS·VA · Plastic Surgery, General Surgery, Dermatology·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 18, 2026
Summary
Effective May 1, 2026, Carelon Medical Benefits Management is adding three surgical procedure codes (Q4369, 30970T, 0971T) to its prior authorization requirements for Medicare Advantage plans in Virginia. Billing teams must implement prior authorization verification for these codes before the effective date to prevent claim denials.
Action Required
By April 30, 2026: Billing team must update the billing system to require prior authorization for CPT codes 30970T and 0971T (breast tumor destruction procedures) and HCPCS code Q4369 (wound repair with Amnioplast) for all Medicare Advantage patients under Carelon Medical Benefits Management in Virginia. Update encounter forms and clinical templates to alert providers that these procedures require prior auth. Configure the system to block claims submission without documented prior authorization approval. Submit all prior authorization requests through Carelon's provider portal (providerportal.com) or via Availity Essentials. Claims submitted without required prior authorization will be denied.