Medicare AdvantagePrior AuthHigh impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·NY · Orthopedics, Cardiology·Provider Bulletin
Effective date
Nov 1, 2026
We identified it
Jul 3, 2026
Summary
Effective November 1, 2026, Carelon Medical Benefits Management is adding 9 new procedure codes across musculoskeletal and cardiology specialties that will require precertification/prior authorization for Anthem's Fully Integrated Dual Eligible (FIDE) Medicare Advantage plans in New York. Billing teams must update authorization workflows and provider education to include these codes before the effective date.
Action Required
By October 15, 2026: Billing team must update all billing system rules and prior authorization workflows to require precertification through Carelon Medical Benefits Management (via provider portal at https://providerportal.com or Availity Essentials) for CPT codes 20932, 20933, 20934, 27280, 64629, C9781, C7517, C7552, and C7553. Update encounter forms and provider alerts to flag these codes for authorization before submission. Contact providers in orthopedics and cardiology to communicate the new requirements. Failure to obtain prior authorization will result in claim denials for Anthem FIDE Medicare Advantage members in New York effective November 1, 2026. Direct questions about clinical guidelines to MedicalBenefitsManagement.guidelines@Carelon.com.