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Medical Policy and Coding Updates - August 2025
Premera Blue Cross·WA, AK · Radiology, Cardiology, Neurology +2 more·Medical Policy
Effective date
Nov 15, 2025
We identified it
Jun 16, 2026
Summary
Starting January 1, 2026, advanced imaging services will require site of care review through Carelon Medical Benefits Management, with specific criteria for when hospital outpatient departments are medically necessary. Multiple radiology and genetic testing guidelines are also being updated effective November 15, 2025.
Action Required
By November 15, 2025: Billing team must implement new Carelon Medical Benefits Management guidelines for radiology services including brain imaging, extremities, spine, vascular, heart, and genetic testing. By January 1, 2026: All advanced imaging claims must be reviewed for appropriate site of care - contact Carelon at MedicalBenefitsManagement.guidelines@Carelon.com for questions. Update prior authorization processes to include site of care justification for hospital outpatient imaging when ancillary services, specialized resources, or continuity of care criteria are not met.