Medicare AdvantagePrior AuthHigh impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)
Anthem BCBS·VA · Cardiology, Radiology, Sleep Medicine +2 more·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 29, 2026
Summary
Carelon Medical Benefits Management has issued multiple precertification/prior authorization requirement updates across multiple service lines (Radiology, Cardiovascular, Sleep, Genetic Testing, Radiation Oncology, and Musculoskeletal) effective on staggered dates from July 1, 2026 through October 1, 2026. These changes apply across Commercial, Medicare Advantage, and Medicaid plans in Virginia, requiring billing teams to update prior authorization submission workflows for each affected service line by their respective effective dates.
Action Required
By June 30, 2026: Billing team must identify all affected service lines at your practice (Radiology, Cardiovascular, Sleep, Genetic Testing, Radiation Oncology, Musculoskeletal) and obtain the complete updated prior authorization guidelines from Carelon Medical Benefits Management. By July 1, 2026: Implement prior authorization requirements for Radiology, Cardiovascular, and Sleep services effective for Medicaid plans. Update billing software, EMR templates, and staff workflows to require prior auth submission before services are rendered. By September 1, 2026: Update prior authorization requirements for Genetic Testing, Radiation Oncology, Cardiovascular, Sleep, and Radiology for Medicare Advantage plans. By October 1, 2026: Implement prior authorization requirements for Genetic Testing, Radiation Oncology, Cardiovascular, Sleep, Radiology, and Musculoskeletal for Commercial plans. Front-desk staff must screen all patients for these service lines to initiate prior authorization requests. Billing team must update claim submission procedures to include prior auth numbers. Failure to obtain required prior authorization will result in claim denials. Reference the full policy text at https://providernews.anthem.com/virginia/articles/precertificationprior-authorization-requirement-updates-care-30287 for specific authorization criteria and submission procedures for each service line.