CommercialPrior AuthHigh impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (August 2026 Newsletter)
Anthem BCBS·VA · Cardiology, Radiation Oncology, Radiology +2 more·Provider Bulletin
Effective date
Nov 1, 2026
We identified it
Jul 29, 2026
Summary
Carelon Medical Benefits Management has issued multiple precertification/prior authorization requirement updates effective November 1, 2026 and December 1, 2026 across multiple service categories (Genetic Testing, Cardiology, Radiation Oncology, Base Surgical, DMEPOS, Radiology, and Radiation Therapy) for Virginia providers. The policy affects Commercial, Medicare Advantage, and Medicaid plan types and requires billing teams to verify and implement updated prior authorization protocols for affected services.
Action Required
By October 15, 2026: Billing team must obtain detailed guideline updates from Carelon for each affected service line (Genetic Testing, Cardiology, Radiation Oncology, Base Surgical, DMEPOS, Radiology, Radiation Therapy). Update billing system prior authorization rules and encounter forms to reflect new requirements effective November 1, 2026 (December 1, 2026 for Radiation Therapy). Notify all providers and front desk staff of changes. Verify that all Commercial, Medicare Advantage, and Medicaid claims for affected services require prior authorization per new guidelines. Claims submitted without updated prior authorization may be denied. Contact Carelon at the newsletter link for specific code updates and documentation requirements.