Medicare AdvantagePrior AuthMedium impact
[California] Carelon Medical Benefits Management, Inc. code updates
Anthem BCBS·CA · General Surgery, Plastic Surgery, Wound Care·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 18, 2026
Summary
Effective May 1, 2026, Carelon Medical Benefits Management will require prior authorization for three breast and wound care procedures: Q4369 (Amnioplast wound repair), 30970T (benign breast tumor laser destruction), and 0971T (malignant breast tumor laser destruction) for Medicare Advantage members in California. Providers must submit prior auth requests through Carelon's provider portal, Availity Essentials, or email before performing these procedures.
Action Required
By April 30, 2026: Billing team must update prior authorization requirements in billing system to flag CPT codes 30970T and 0971T and HCPCS code Q4369 as requiring prior authorization through Carelon Medical Benefits Management for all California Medicare Advantage claims. Providers and front desk staff must be notified to submit prior authorization requests before scheduling or performing these procedures using Carelon's provider portal (providerportal.com) or Availity Essentials. Failure to obtain prior authorization will result in claim denials. Update encounter forms and provider guidelines accordingly.