Medicare AdvantagePrior AuthHigh impact
[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·CA · 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 Medicare Advantage PPO plans in California now require precertification/prior authorization through Carelon Medical Benefits Management for 16 specific DMEPOS codes covering lumbar-sacral orthoses, knee orthoses, ankle-foot orthoses, and the Flex Foot System. All ordering and servicing providers must submit prior authorization requests before dispensing these devices or risk claim denials.
Action Required
By October 15, 2026: Billing team and providers must update internal workflows and billing systems to require prior authorization through Carelon Medical Benefits Management for all claims using HCPCS codes L0631, L0637, L0639, L0648, L0650, L0651, L1832, L1843, L1844, L1845, L1846, L1851, L1852, L1932, L1951, and L5980 when billed to Anthem Blue Cross Medicare Advantage PPO plans in California. Configure billing software to flag these codes for mandatory authorization before claim submission. Train ordering and servicing providers to submit requests via Carelon's provider portal (https://providerportal.com) or Availity Essentials (https://Availity.com) before dispensing devices. For guideline questions, contact MedicalBenefitsManagement.guidelines@Carelon.com. Failure to obtain prior authorization will result in claim denials.