CommercialPrior AuthMedium impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·NY · Radiation Oncology, General Surgery, Plastic Surgery·Provider Bulletin
Effective date
Dec 1, 2026
We identified it
Jul 11, 2026
Summary
Effective December 1, 2026, Anthem Blue Cross and Blue Shield in New York will require prior authorization through Carelon Medical Benefits Management for two intraoperative radiation therapy codes (CPT 19294 and 19297) used in breast cancer treatment. Billing teams must update workflows to obtain precertification before submitting claims for these procedures.
Action Required
By November 15, 2026: Billing team and providers must implement prior authorization requirement for CPT 19294 and CPT 19297. Update billing system to flag these codes as requiring precertification before claim submission. Providers and clinical staff must submit authorization requests to Carelon Medical Benefits Management via their provider portal (https://providerportal.com) or Availity Essentials (https://Availity.com) BEFORE surgery is scheduled or performed. Update encounter forms and pre-operative checklists to remind ordering providers. Communicate with radiation oncology and surgical teams that these procedures cannot proceed without documented prior authorization. Failure to obtain prior auth will result in claim denials. For guideline questions, contact MedicalBenefitsManagement.guidelines@Carelon.com.