Medicare AdvantagePrior AuthHigh impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·NY · Orthopedics, Physical Therapy, PM&R (Physical Medicine & Rehab) +2 more·Provider Bulletin
Effective date
Nov 1, 2026
We identified it
Jul 8, 2026
Summary
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage plans in New York will require prior authorization through Carelon Medical Benefits Management for 12 specific DMEPOS codes related to lumbar-sacral orthoses, knee orthoses, ankle-foot orthoses, and the Flex Foot System. Ordering and servicing providers must submit precertification requests via the Carelon provider portal, Availity Essentials, or email before dispensing these devices.
Action Required
By October 31, 2026: Billing team and providers must implement prior authorization requirements for all claims using DMEPOS codes L0631, L0637, L0639, L0648, L0650, L0651, L1832, L1843, L1844, L1845, L1846, L1851, L1852, L1932, L1951, and L5980 for Anthem Blue Cross and Blue Shield Medicare Advantage members in New York. Update billing system rules to flag these codes and require authorization before claim submission. Train ordering providers and DMEPOS suppliers to submit precertification requests via Carelon's provider portal (https://providerportal.com), Availity Essentials (https://Availity.com), or email (MedicalBenefitsManagement.guidelines@Carelon.com) for all dates of service on or after November 1, 2026. Add these codes to encounter forms and pre-authorization checklists. Failure to obtain prior authorization will result in claim denials for affected members.