CommercialPrior AuthHigh impact
[Ohio] July 2026 Provider Newsletter
Anthem BCBS·OH · Psychiatry, Pharmacy·Newsletter
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
This Ohio newsletter contains multiple policy updates effective July-October 2026 affecting billing, prior authorization, reimbursement, and clinical guidelines across Commercial, Medicare Advantage, and Medicaid plans. Key changes include: (1) Commercial inpatient claims requiring correct primary diagnosis codes effective August 1, 2026; (2) Behavioral health prior authorization requirements for substance use disorder services effective October 1, 2026 for Medicaid; (3) MyCare Ohio home health claims requiring bill type 329 effective June 23, 2026; (4) Carelon clinical appropriateness guidelines and specialty pharmacy precertification list expansions effective September-October 2026; and (5) provider preventable conditions reimbursement policy reminder effective October 1, 2026.
Action Required
REQUIREMENTS - Multiple staggered deadlines: (1) By August 1, 2026: Billing team must validate all inpatient facility claims include correct primary diagnosis (PDX) codes in billing system. Update claim submission templates to flag non-reimbursable PDX codes. Non-compliant claims will require resubmission. (2) By June 23, 2026 (immediate): MyCare Ohio home health claims must be submitted with bill type 329. Update billing software validation rules. (3) By October 1, 2026: Billing team must update prior authorization workflows for Medicaid/MyCare Ohio substance use disorder (SUD) services and levels of care (LOC) per Behavioral Health PA requirements. Train staff on new PA submission process. (4) By September 19, 2026: Billing and clinical staff must review updated Carelon Medical Benefits Management Clinical Appropriateness Guidelines. Update authorization protocols accordingly. (5) By October 1, 2026: Update specialty pharmacy precertification list in billing system per Carelon expansion. Obtain prior authorization before dispensing affected specialty medications. (6) By October 1, 2026: Implement provider preventable conditions (PPC) reimbursement policy for professional and facility claims. Ensure compliance documentation is included with submissions. All plan types affected - coordinate across Commercial, Medicare Advantage, and Medicaid.