Medicare AdvantageDocumentationHigh impact
[Georgia] Clinical Criteria updates
Anthem BCBS·GA · Allergy & Immunology, Endocrinology, Hematology +5 more·Provider Bulletin
Effective date
Jul 23, 2026
We identified it
Jun 25, 2026
Summary
Anthem Blue Cross Blue Shield (Georgia) has revised 25 clinical criteria policies and added 2 new ones effective July 23, 2026, covering specialty drugs and biologics used in Medicare Advantage medical drug benefits. These revised criteria may affect medical necessity requirements, prior authorization rules, and billing documentation for affected medications. Billing teams must review updated clinical criteria to ensure claims align with new medical necessity standards.
Action Required
By July 23, 2026: Billing team and clinical staff must access Anthem's Clinical Criteria page to review detailed changes for the 27 revised/new policies (CC-0003, CC-0011, CC-0027, CC-0029, CC-0058, CC-0065, CC-0068, CC-0072, CC-0104, CC-0124, CC-0127, CC-0128, CC-0142, CC-0149, CC-0159, CC-0174, CC-0182, CC-0213, CC-0222, CC-0227, CC-0229, CC-0235, CC-0236, CC-0263, CC-0300, CC-0301). Identify which policies affect drugs/biologics used in your practice and update: (1) internal documentation requirements in EMR/billing system for each affected medication; (2) prior authorization protocols if medical necessity criteria changed; (3) billing submission rules to match new requirements. Coordinate with providers to ensure prescribing documentation meets updated clinical criteria. Watch for separate authorization requirements notice from Anthem. Failure to align billing with updated clinical criteria will result in claim denials for non-compliant submissions.