MedicaidPrior AuthMedium impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·NY · Oncology, Genetics, Neurology·Provider Bulletin
Effective date
Aug 1, 2026
We identified it
Jun 25, 2026
Summary
Effective August 1, 2026, CPT code 81345 (TERT gene analysis for thyroid carcinoma and glioblastoma multiforme) now requires precertification/prior authorization through Carelon Medical Benefits Management for New York Medicaid beneficiaries. Ordering and servicing providers must submit authorization requests via the Carelon provider portal, Availity Essentials, or email before performing this genetic test.
Action Required
By July 31, 2026: Billing team and ordering providers must implement prior authorization requirement for CPT 81345 in all systems and workflows. Update billing software to flag CPT 81345 as requiring Carelon Medical Benefits Management precertification before claim submission. Providers must obtain prior authorization through one of three methods: (1) Carelon provider portal at https://providerportal.com (24/7 access, recommended), (2) Availity Essentials at https://Availity.com, or (3) email to MedicalBenefitsManagement.guidelines@Carelon.com. Add CPT 81345 to encounter forms and pre-visit planning tools with a reminder to obtain authorization. Update front desk and clinical staff that this genetic test requires precertification. Failure to obtain prior authorization will result in claim denials for New York Medicaid members effective August 1, 2026.