[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (August 2026 Newsletter)

IMMEDIATE ACTION REQUIRED: By September 15, 2026 (before first effective date of October 1, 2026): (1) Billing team and clinical leadership must access the full policy documents via the Anthem provider portal (https://providernews.anthem.com/ohio) for each affected specialty category listed: Genetic Testing, Surgical, DME/POS, Cardiology, Radiation Therapy, Sleep, Radiation Oncology, and Cardiovascular. (2) Extract specific CPT/HCPCS codes affected by each update and identify which prior authorization thresholds or requirements have changed. (3) Update billing software and EMR systems to enforce new prior authorization requirements for each affected code. (4) Create or modify encounter templates and charge capture workflows to require documentation of prior authorization status before claim submission. (5) Alert all providers and clinical staff in these specialties about new requirements, particularly noting staggered effective dates (October 1, December 1, November 1 vary by service line and plan type). (6) Implement monitoring process to track compliance with new prior auth requirements. Failure to obtain required prior authorizations before service delivery will result in claim denials under these updated policies.