MedicaidPrior AuthMedium impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·OH · Oncology, Cardiology, Genetics +1 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
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.
Action Required
By September 15, 2026: Billing 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. Providers must submit pre-authorization requests via Carelon's provider portal (https://providerportal.com) or Availity Essentials (https://Availity.com) before ordering these tests. Update encounter forms and provider communications to remind ordering physicians that these genetic tests require prior authorization effective October 1, 2026. Claims submitted without prior authorization will be subject to denial.