Medicare AdvantagePrior AuthMedium impact
[Ohio] Carelon Medical Benefits Management, Inc. code updates
Anthem BCBS·OH · General Surgery, Plastic Surgery, Wound Care·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 18, 2026
Summary
Effective May 1, 2026, three specific surgical procedure codes (Q4369, 30970T, and 0971T) will require prior authorization through Carelon Medical Benefits Management for Ohio Medicare Advantage members. Providers must submit prior auth requests via the Carelon provider portal, Availity Essentials, or email before performing these procedures to avoid claim denials.
Action Required
By April 30, 2026: Billing team and providers must implement prior authorization requirements for CPT codes 30970T and 0971T (breast tumor destruction procedures) and HCPCS code Q4369 (amnioplast wound repair). Update billing software to flag these codes for Ohio Medicare Advantage claims and require prior auth submission before service delivery. Establish workflow to submit authorization requests via Carelon's provider portal at providerportal.com (preferred method for real-time processing), or through Availity Essentials at Availity.com. Train front desk and clinical staff to communicate new authorization requirements to patients and providers. Failure to obtain prior authorization will result in claim denials.