← Back to list
[Virginia] Clinical Criteria updates
Act
by Jul 25, 2026
Effective date
Aug 1, 2026
Identified
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.
Get alerts when payers change rules like this one
We check Anthem BCBS and other payers every day and email you when a change matches your specialty and state.
Get Anthem BCBS alertsPolicy Monitoring is free. No card required.
What to do
by Jul 25, 2026 · 6 steps
01Billing 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.
02For each affected specialty drug (CC-0002 through CC-0301), identify whether prior authorization, specific medical documentation, or coding edits apply.
03Update billing software, EMR templates, and prior authorization workflows to enforce new/revised medical necessity requirements as of August 1, 2026.
04Contact HealthKeepers via the provided email channel to clarify authorization rules for any ambiguous criteria.
05Failure to comply with revised criteria will result in claim denials and payment recoupment for services billed without meeting updated medical necessity standards.
06Communicate changes to all clinical and administrative staff handling specialty medication billing.
Original notice
[Virginia] Clinical Criteria updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Virginia] Clinical Criteria updatesHighEffective Nov 29, 2026 · Provider Bulletin[Virginia] Clinical Criteria updatesHighEffective Nov 20, 2026 · Provider Bulletin[Virginia] Clinical Criteria updates (September 2026 Newsletter)MediumNo effective date · Provider Bulletin[Virginia] Clinical Criteria updatesHighEffective Sep 28, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list