MedicaidAdministrativeLow impact
[Virginia] Efficacy through efficiency — emphasizing utilization management
Anthem BCBS·VA·Prior Authorization
Effective date
May 20, 2026
We identified it
May 21, 2026
Summary
Anthem HealthKeepers Plus (Virginia Medicaid) has published clarification on their utilization management (UM) process, emphasizing that UM decisions are based on appropriateness of care and member coverage. The policy explicitly prohibits financial incentives or performance metrics that reward denials, and reaffirms access to physician reviewers for UM appeal discussions. This is informational guidance rather than a substantive policy change.
Action Required
No immediate action required. Billing team should be aware that Anthem HealthKeepers Plus continues to accept prior authorization requests via Availity, phone (800-901-0020), or fax (800-964-3627). Providers may request copies of UM criteria from Medical Management and discuss denials with physician reviewers during business hours (Monday-Friday, 8:30 a.m. to 5 p.m. ET). Bookmark the provider resource link (https://anthem.com/va/provider) for access to updated medical policies and clinical practice guidelines. No changes to existing billing workflows or documentation requirements are indicated.