CommercialPrior AuthMedium impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·OH · 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 (Ohio) now requires precertification/prior authorization for two intraoperative radiation therapy CPT codes (19294 and 19297) used in breast cancer treatment. All requests for these codes must be submitted through Carelon Medical Benefits Management via their provider portal, Availity Essentials, or email before services are rendered.
Action Required
By November 15, 2026: Billing team must update the billing system to require prior authorization for CPT codes 19294 and 19297 for all Anthem Blue Cross and Blue Shield (Ohio) commercial claims. Providers and surgical coordinators must be notified to submit precertification requests to Carelon Medical Benefits Management through the provider portal (https://providerportal.com), Availity Essentials (https://Availity.com), or email (MedicalBenefitsManagement.guidelines@Carelon.com) BEFORE scheduling or performing these intraoperative radiation therapy procedures. Update clinical workflows and encounter forms to include prior authorization checkpoints for partial mastectomy cases involving radiation therapy. Claims submitted without prior authorization will be subject to denial. Reference UM AROW #A2026M5988 when contacting Carelon for authorization questions.