MedicaidPrior AuthMedium impact
[Virginia] Prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·VA · Nuclear Medicine, Radiology, Oncology·Provider Bulletin
Effective date
Nov 1, 2026
We identified it
Jul 15, 2026
Summary
Effective November 1, 2026, CPT code A9552 (Fluorodeoxyglucose F-18 FDG diagnostic) will require prior authorization through Carelon Medical Benefits Management for Virginia Medicaid (HealthKeepers, Inc. and Anthem HealthKeepers Plus) members. Ordering and servicing providers must submit prior authorization requests via the Carelon provider portal, Availity Essentials, or other designated channels before delivering this service.
Action Required
By October 31, 2026: Billing team must update billing system rules to require prior authorization for HCPCS code A9552 (Fluorodeoxyglycose F-18 FDG diagnostic). Providers ordering this service must submit prior authorization requests to Carelon Medical Benefits Management via: (1) Carelon provider portal at https://providerportal.com (available 24/7 for real-time processing), or (2) Availity Essentials at https://Availity.com. Update encounter templates and provider workflows to flag A9552 for mandatory prior authorization before service delivery. Train front desk and clinical staff to ensure no A9552 claims are processed without Carelon pre-authorization. Contact Carelon at MedicalBenefitsManagement.guidelines@Carelon.com for guideline questions. Claims for A9552 without prior authorization will be denied.