MedicaidPrior AuthHigh impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (June 2026 Newsletter)
Anthem BCBS·OH · Cardiology, Genetics, Oncology +3 more·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 29, 2026
Summary
Carelon Medical Benefits Management has updated prior authorization requirements across multiple clinical areas (Genetic Testing, Cardiovascular, Radiology, Sleep, Musculoskeletal, and Radiation Oncology) effective on staggered dates from July 1, 2026 through October 1, 2026. These changes apply differently to Medicaid, Medicare Advantage, and Commercial plans in Ohio, requiring the billing team to implement plan-specific prior authorization workflows for affected service lines.
Action Required
By June 15, 2026: Billing team must identify and document all prior authorization requirement changes by plan type (Medicaid, Medicare Advantage, Commercial) and specialty area. Create a detailed implementation matrix mapping each service line to its specific effective date (Medicaid changes effective 7/1/2026; Medicare Advantage changes effective 9/1/2026; Commercial changes effective 10/1/2026). Update billing system rules and prior authorization workflows for: Genetic Testing, Cardiovascular, Radiology, Sleep, Musculoskeletal, and Radiation Oncology services. Before each effective date, notify providers and front desk staff of new prior authorization requirements for their respective plan types. Monitor the Carelon provider portal for detailed policy documents linked in this bulletin and implement corresponding documentation requirements. Flag the retracted Cardiovascular Commercial article (retracted 7/17/2026) and use only the updated version dated 5/27/2026. Failure to obtain required prior authorizations will result in claim denials.