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[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Act
by Mar 20, 2026
Effective date
Apr 4, 2026
Identified
May 18, 2026
Summary
Carelon Medical Benefits Management updated clinical appropriateness guidelines for oncologic imaging, genetic testing, and hereditary cancer syndromes effective April 4, 2026 for Ohio Medicaid and MyCare plans. Multiple guidelines now align with NCCN standards, affecting cancer screening, diagnostic imaging, and genetic testing coverage criteria. Six new genetic testing CPT codes (81218, 81310, 81334, 81338, 81339, 81345) were added, and specific hereditary syndromes and cancer types have expanded or new indications.
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What to do
by Mar 20, 2026 · 3 steps
01Billing team must update prior authorization protocols and claims processing rules in billing software to reflect new genetic testing codes (81218, 81310, 81334, 81338, 81339, 81345) and updated clinical appropriateness guidelines for Anthem Blue Cross and Blue Shield Ohio Medicaid and MyCare plans.
02Review the complete updated guidelines at providerportal.com or via Carelon's guidelines email (MedicalBenefitsManagement.guidelines@Carelon.com) to understand new/expanded indications for: breast cancer screening (ACR/NCCN alignment), lung cancer screening (removal of signs/symptoms requirement), pancreatic cancer screening, ovarian cancer (rising tumor markers allowance), hereditary cancer testing (expanded genes and syndromes), and prostate cancer (PSMA PET updates, removal of intraductal/cribriform criteria).
03Update encounter forms and provider alerts to reflect these changes.
If missed: Failure to apply correct guidelines may result in claim denials or retroactive recoupment for services rendered April 4, 2026 onward.
Codes mentioned
812188131081334813388133981345
Original notice
[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
providernews.anthem.com · Always check the source before changing claims.
Related changes
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