MedicaidCoverageMedium impact
[California] Carelon Medical Benefits Management, Inc. updates
Anthem BCBS·CA · Radiology, Cardiology, Sleep Medicine +5 more·Provider Bulletin
Effective date
Apr 23, 2026
We identified it
May 18, 2026
Summary
Carelon Medical Benefits Management is updating clinical appropriateness guidelines for Anthem Medicaid effective April 23, 2026, affecting genetic testing, radiology imaging, cardiovascular procedures, sleep disorders, surgical services, and musculoskeletal procedures. Existing prior authorization requirements remain unchanged, and no new prior auth requirements are being implemented at this time; however, practices should monitor for future notices regarding any new or modified authorization requirements.
Action Required
By April 22, 2026: Billing team and clinical staff should review updated Carelon clinical appropriateness guidelines at the provided URL (https://providernews.anthem.com/california/articles/carelon-medical-benefits-management-inc-updates-28419) for the following service categories: Genetic Testing (Somatic Tumor Testing, Genetic Liquid Biopsy, Pharmacogenetic Testing), Radiology (Brain, Extremities, Heart, Spine, Oncologic, Vascular Imaging), Cardiovascular (Diagnostic Coronary Angiography, Endovascular Revascularization), Sleep Disorder Management, Surgical Services (Level of Care for Surgical Procedures), and Musculoskeletal procedures (Joint Surgery, Small Joint Surgery, Spine Surgery). Update clinical documentation templates and provider order entry systems to reflect any guideline clarifications. Establish monitoring process for future bulletins regarding potential new prior authorization or level of care review requirements. Distribute guidelines to all providers and clinical staff.