MedicaidPrior AuthMedium impact
[Virginia] MCG Care Guidelines 30th edition
Anthem BCBS·VA · Psychiatry, Cardiology, Cardiothoracic Surgery +4 more·Provider Bulletin
Effective date
Jun 1, 2026
We identified it
May 20, 2026
Summary
HealthKeepers, Inc. (Virginia Medicaid) is upgrading to MCG Care Guidelines 30th edition effective June 1, 2026. This introduces new clinical guidelines for psychosocial education, ketamine for treatment-resistant depression, transcatheter mitral valve repair, cardiac rehabilitation, pediatric bipolar disorder assessments, and dual organ transplant indications. Billing and prior authorization workflows may require updates to align with these new guideline modules.
Action Required
By May 31, 2026: Billing and clinical teams must review the updated MCG Care Guidelines 30th edition modules (BHG, ISC, GRG, RFC, CCG) on the HealthKeepers provider portal. Update prior authorization decision logic in the billing system to reflect new guideline criteria for: psychosocial education, ketamine therapy, transcatheter valve procedures, cardiac rehabilitation, pediatric bipolar assessments, and dual organ transplants. Train providers and prior auth staff on new guideline thresholds. Contact HealthKeepers Provider Services (800-901-0020) with questions. Failure to align with updated guidelines may result in claim denials or improper prior auth determinations after the effective date.