Medicare AdvantageAdministrativeHigh impact
[California] August 2026 Provider Newsletter
Anthem BCBS·CA·Newsletter
Effective date
Oct 1, 2026
We identified it
Aug 2, 2026
Summary
This August 2026 California provider newsletter from Anthem contains multiple policy updates effective September-November 2026 and October 2026, including changes to prior authorization requirements, telehealth claims editing, observation service billing, outpatient facility coding, pharmacy precertification, and a shift to electronic claims/payments to avoid paper administrative fees. The billing team must implement multiple distinct changes across different plan types with staggered effective dates.
Action Required
REQUIREMENTS:
By September 1, 2026:
- Billing team must review and implement observation service billing changes per CMS requirements for Medicare Advantage claims. Update billing system validation rules and provider documentation requirements.
- Billing team must implement ICD-10-CM Excludes1 editing for telehealth claims for Medicare Advantage and Medicaid. Update claim scrubbing logic to catch and prevent denials from code conflicts.
- Billing team must review outpatient facility coding updates for Commercial plans. Update encoder and billing system to reflect new coding guidelines. Providers must document facility type accurately on claims.
- Billing team must ensure professional claims for inpatient admissions include accurate Place of Service (POS) reporting for Medicaid. Update claim submission templates.
By October 1, 2026:
- Billing team must transition from paper claims and payment methods to electronic alternatives for Medicare Advantage plans. Update all claim submission workflows to use electronic submission only. Eliminate paper claim processes to avoid administrative fees.
By November 1, 2026:
- Billing team must implement new precertification/prior authorization requirements for Medicare Advantage through Carelon Medical Benefits Management. Update prior auth verification process and submission procedures.
- Billing team must implement updated precertification/prior authorization requirements for Medicare Advantage plans. Verify all requirements are loaded in authorization system.
- Billing team must implement updated prior authorization and step therapy requirements for Medicaid. Update pharmacy and medical benefit authorization processes.
- Billing team must implement expanded Specialty Pharmacy precertification list for Medicare Advantage. Update pharmacy authorization system and prior auth protocols.
Consequences: Failure to meet these deadlines will result in claim denials, administrative fee assessments, and compliance violations with payer requirements.