Medicare AdvantagePrior AuthHigh impact
[New York] Precertification/prior authorization change to the parenteral nutrition codes listed
Anthem BCBS·NY · Gastroenterology, General Surgery, Critical Care +3 more·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 27, 2026
Summary
Effective July 1, 2026, Anthem Medicare Advantage plans in New York will require prior authorization for 20 parenteral nutrition-related HCPCS codes (B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200). Prior authorization must be obtained before dispensing to avoid claim denials. Services must meet CMS LCD L38953 criteria, requiring documentation of a permanently nonfunctioning gastrointestinal tract.
Action Required
By June 30, 2026: Billing team and clinical staff must implement prior authorization workflow for all 19 parenteral nutrition codes listed. (1) Update billing system to flag and hold all B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, and B5200 claims for Anthem Medicare Advantage members until prior auth is obtained. (2) Clinical staff must obtain prior authorization from Anthem before dispensing parenteral nutrition by submitting medical records documenting permanently nonfunctioning gastrointestinal tract per CMS LCD L38953 requirements. (3) Billing team should reference detailed prior auth requirements on https://anthem.com/provider (Resources tab) or https://Availity.com for contracted providers. (4) Train all relevant staff on new requirement and submission process via Availity Essentials or Provider Services contact. Failure to obtain prior authorization will result in claim denials and delayed member access to medically necessary services.