Medicare AdvantagePrior AuthHigh impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·OH · Sleep Medicine, Radiation Oncology, Radiology +1 more·Provider Bulletin
Effective date
Nov 1, 2026
We identified it
Jul 15, 2026
Summary
Effective November 1, 2026, Carelon Medical Benefits Management is adding 13 new CPT and HCPCS codes across sleep medicine, radiation oncology, radiology, and cardiovascular specialties to the precertification/prior authorization requirement for all Ohio FIDE (Fully Integrated Dual Eligible) plans. Providers must obtain prior authorization before delivering these services or face potential claim denials.
Action Required
By October 1, 2026 (30 days before effective date): Billing team and providers must update billing software, EMR systems, and prior authorization workflows to require precertification through Carelon Medical Benefits Management for all 12 affected codes (64568, C1607, 77402, 77407, 77412, 70471, 70473, A9616, C7568, C7569, C7570, C7571). Configure system alerts and encounter forms to prompt providers to submit prior auth requests before scheduling or performing procedures. Staff should be trained on submission methods: Carelon provider portal (https://providerportal.com - available 24/7) or Availity Essentials (https://Availity.com). For MyCare Ohio (Ohio FIDE plans only): Route all prior auth requests to Carelon Medical Benefits Management. Claims submitted without required prior authorization will be denied.