Medicare AdvantageDocumentationMedium impact
[Ohio] Clinical Criteria updates
Anthem BCBS·OH · Oncology, Hematology, Infectious Disease +2 more·Provider Bulletin
Effective date
Apr 4, 2026
We identified it
May 18, 2026
Summary
Anthem has revised clinical criteria for 17 existing medical drug benefit policies and added 3 new policies effective April 4, 2026. These changes affect medical necessity requirements and coding edits for specialized medications including oncology agents, immunology drugs, and rare disease treatments. The billing team must access updated clinical criteria documentation to ensure claims comply with new or modified medical necessity requirements.
Action Required
By April 4, 2026: Billing team must access Anthem's Clinical Criteria page (referenced in policy) to review the specific medical necessity requirement changes for each of the 20 updated criteria listed (CC-0002, CC-0010, CC-0027, CC-0028, CC-0043, CC-0072, CC-0079, CC-0110, CC-0121, CC-0124, CC-0127, CC-0128, CC-0130, CC-0157, CC-0187, CC-0193, CC-0229, CC-0242, CC-0276, CC-0294, CC-0295, CC-0296). Providers must update their clinical documentation practices to align with revised medical necessity criteria for these specialty medications. Forward this notice to all clinical and billing staff, and coordinate with providers to ensure they document according to new criteria for patients receiving these medications. Note: Authorization rules are communicated separately; this notice covers clinical criteria only and applies exclusively to medical drug benefits, not pharmacy services.