MedicaidDocumentationMedium impact
[Ohio] Clinical Criteria updates
Anthem BCBS·OH · Neurology, Oncology, Hematology +6 more·Provider Bulletin
Effective date
Sep 26, 2026
We identified it
Jun 25, 2026
Summary
Anthem Blue Cross and Blue Shield Ohio Medicaid revised 16 clinical criteria policies effective September 26, 2026, covering specialty medications and biologics across multiple therapeutic categories including rare disease treatments, oncology agents, immunology drugs, and ophthalmology therapies. The revisions update medical necessity requirements for drugs administered under the medical benefit (not pharmacy benefit), requiring immediate review to identify any changes to prior authorization or documentation requirements.
Action Required
By September 26, 2026: Billing team must access the full Clinical Criteria policies for each of the 16 revised criteria via Anthem's Clinical Criteria page (https://providernews.anthem.com/ohio/) to identify specific changes to medical necessity requirements. For each revised criterion (CC-0012, CC-0035, CC-0087, CC-0102, CC-0159, CC-0199, CC-0220, CC-0250, CC-0020, CC-0041, CC-0072, CC-0075, CC-0160, CC-0166, CC-0167, CC-0182, CC-0227), document any new or removed requirements and update prior authorization workflows, clinical documentation templates, and billing system rules accordingly. Notify prescribing providers of any changes to submission requirements for affected specialty medications. Prior authorization rules will be communicated separately via additional Anthem notice. This applies only to medical drug benefits under Anthem Ohio Medicaid managed care plans, not pharmacy services. Failure to implement required changes may result in claim denials for non-compliance with updated medical necessity criteria.