[Ohio] June 2026 Provider Newsletter

REQUIREMENTS: Due to multiple effective dates in this newsletter, implement changes by their respective dates: • By June 12, 2026: Billing team must review and implement Medical Policies and Clinical Utilization Management Guidelines updates for Medicaid. Update billing system rules and denial handling protocols accordingly. • By June 1, 2026: Billing team must ensure accurate E/M service coding for MyCare Ohio claims. Update provider encounter forms and billing software to reflect correct coding requirements. Provide training to coding staff. Inaccurate coding will result in claim denials or payment adjustments. • By July 1, 2026: (1) Update prior authorization requirements for parenteral nutrition codes for Medicare Advantage plans. (2) Implement prior authorization and step therapy updates for medications billed under the medical benefit for Medicaid. (3) Ensure billed charges and units are accurate on professional claims across all plan types. Update billing software validation rules and staff training. Claims with inaccurate charges/units will be denied. • By July 17, 2026: Billing team must ensure billed charges and units are accurate on professional claims for Commercial, Medicare Advantage, Medicaid, and MyCare Ohio. Implement billing system edits to prevent submission of claims with billing/unit errors. • By September 1, 2026: (1) Update prior authorization requirements for Medicare Advantage plans per recent changes. (2) Implement prior authorization requirement changes for MyCare Ohio per Carelon Medical Benefits Management updates. (3) Update E/M services coding for MyCare Ohio to reflect new requirements. Notify providers of changes and update billing system rules. Failure to obtain required prior authorizations will result in claim denials. • Immediately: Billing team should review all four categories of prior authorization updates (parenteral nutrition, general precertification/prior authorization changes, Medicaid pharmacy updates, and Carelon MBM updates) to identify codes requiring changes in your billing system. Contact Anthem for specific code lists if not provided in detailed policy documents.