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[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective date
Nov 1, 2026
Identified
Jul 2, 2026
Summary
Effective November 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 Anthem Blue Cross and Blue Shield Medicare Advantage members in New York. Providers must submit authorization requests via Carelon's provider portal, Availity Essentials, or email before performing this genetic test.
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What to do
Action · 5 steps
01Before November 1, 2026: Billing team and ordering providers must implement prior authorization requirement for CPT 81345 in all billing and ordering workflows.
02Update billing system/EMR to flag CPT 81345 as requiring prior authorization for Anthem Medicare Advantage New York members.
03Instruct providers and lab personnel that CPT 81345 cannot be performed without prior approval from Carelon Medical Benefits Management.
04Establish process to submit precertification requests via Carelon provider portal (https://providerportal.com), Availity Essentials (https://Availity.com), or email (MedicalBenefitsManagement.guidelines@Carelon.com) before patient testing.
05Add CPT 81345 to encounter forms and test requisition templates with notation that prior auth is required.
If missed: Failure to obtain prior authorization will result in claim denials and potential member balance issues.
Codes mentioned
81345
Original notice
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
providernews.anthem.com · Always check the source before changing claims.
Related changes
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