CommercialPrior AuthMedium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·VA · Oncology, General Surgery, Radiation Oncology·Provider Bulletin
Effective date
Dec 1, 2026
We identified it
Jul 11, 2026
Summary
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (including HealthKeepers, Inc.) in Virginia now requires precertification/prior authorization for two radiation therapy CPT codes (19294 and 19297) related to intraoperative and interstitial radiotherapy during partial mastectomy procedures. All PPO and HMO commercial plans are affected. Billing teams must implement prior authorization requirements before this date or claims will be denied.
Action Required
By November 30, 2026: Billing team must update billing software to require prior authorization through Carelon Medical Benefits Management for CPT codes 19294 and 19297 for all Virginia Anthem Blue Cross and Blue Shield and HealthKeepers, Inc. commercial plans (PPO and HMO). Update encounter templates and provider order forms to trigger authorization requirements for these codes. Providers must submit prior authorization requests via Carelon's provider portal (https://providerportal.com) or Availity Essentials (https://Availity.com) before billing. Failure to obtain prior authorization will result in claim denials. Train front desk and clinical staff to flag these procedures at scheduling. Contact Carelon Medical Benefits Management at MedicalBenefitsManagement.guidelines@Carelon.com with questions.