MedicaidPrior AuthHigh impact
[Virginia] Clinical Criteria updates
Anthem BCBS·VA · Oncology, Hematology, Neurology +9 more·Provider Bulletin
Effective date
Aug 1, 2026
We identified it
Jun 26, 2026
Summary
HealthKeepers, Inc. (Anthem) has revised 29 clinical criteria policies for specialty medications and biologics administered as medical benefits (not pharmacy), and added 2 new criteria policies, effective August 1, 2026. The revisions involve medical necessity requirements and coding edits for high-cost injectable and infused drugs including cancer immunotherapies, clotting factors, growth hormones, and rare disease agents. Billing teams must obtain the full revised criteria documents to understand specific authorization and documentation requirements for each drug.
Action Required
By July 25, 2026: Billing team and providers must access and review all 31 revised/new clinical criteria policies via HealthKeepers' Clinical Criteria page (https://providernews.anthem.com/virginia/articles/clinical-criteria-updates-effective-posting-date-notificatio-30771) for Anthem HealthKeepers Plus Medicaid members in Virginia. For each affected specialty drug (CC-0002 through CC-0301), identify whether prior authorization, specific medical documentation, or coding edits apply. Update billing software, EMR templates, and prior authorization workflows to enforce new/revised medical necessity requirements as of August 1, 2026. Contact HealthKeepers via the provided email channel to clarify authorization rules for any ambiguous criteria. Failure to comply with revised criteria will result in claim denials and payment recoupment for services billed without meeting updated medical necessity standards. Communicate changes to all clinical and administrative staff handling specialty medication billing.