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Anthem BCBSMedicaid · Prior Auth · Provider Bulletin · OH · Oncology, Cardiology, Genetics +1 moreMedium impact

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

Act
by Sep 15, 2026
Effective date
Oct 1, 2026
Identified
Jun 13, 2026

Summary

Effective October 1, 2026, Carelon Medical Benefits Management will require prior authorization for 16 specific genetic testing CPT codes covering oncology, rare diseases, cardiology, hereditary cancer, transplant medicine, and pharmacogenomic analysis. Billing teams must update systems to flag these codes for pre-authorization submission before claims are processed.

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What to do

by Sep 15, 2026 · 4 steps
01Billing team must update billing system to require prior authorization for all 15 genetic testing codes (0020M, 0452U, 0453U, 0454U, 0460U, 0461U, 0465U, 0466U, 0467U, 0469U, 0471U, 0473U, 0474U, 0475U, 81558) through Carelon Medical Benefits Management.
02Providers must submit pre-authorization requests via Carelon's provider portal (https://providerportal.com) or Availity Essentials (https://Availity.com) before ordering these tests.
03Update encounter forms and provider communications to remind ordering physicians that these genetic tests require prior authorization effective October 1, 2026.
04Claims submitted without prior authorization will be subject to denial.

Codes mentioned

81558

Original notice

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
providernews.anthem.com · Always check the source before changing claims.
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Related changes

See all Anthem BCBS changes →
[New York] Carelon Medical Benefits Management code updatesMediumEffective Oct 1, 2026 · Provider Bulletin[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits ManagementLowEffective Feb 1, 2027 · Provider Bulletin[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits ManagementHighEffective Feb 1, 2027 · Provider Bulletin[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits ManagementHighEffective Jan 1, 2027 · Provider BulletinBrowse every Anthem BCBS change in the policy list

Related policy hubs

Anthem BCBS policiesOH policy changesOncologyCardiologyGeneticsInternal MedicineCode 81558

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