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[Georgia] Clinical Criteria updates

Anthem BCBS·GA · Oncology, Hematology, Allergy & Immunology +7 more·Provider Bulletin
Effective date
Jul 23, 2026
We identified it
Jul 1, 2026
Days to comply
22 days

Summary

Anthem Blue Cross Blue Shield (Georgia) has revised 27 clinical criteria policies for specialty drugs covered under Medicare Advantage medical benefits, effective July 23, 2026. These revisions update medical necessity requirements for high-cost biologics, immunoglobulins, and rare disease treatments. Billing teams must review updated clinical criteria before claims submission to ensure compliance with new medical necessity edits.

Action Required

Before Jul 23, 2026
By July 23, 2026: Billing team must access Anthem's Clinical Criteria page and review all 27 revised 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) and 2 new policies (CC-0300, CC-0301). Update billing system rules and clinical edit logic to reflect new medical necessity requirements for each criterion. Alert providers in oncology, hematology, immunology, and rare disease specialties to ensure documentation supports clinical criteria compliance. Obtain separate authorization notice for any new prior authorization rules. Failure to implement updated criteria may result in claim denials or recoupment for non-compliant submissions for Medicare Advantage members in Georgia.

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