Medicare AdvantagePrior AuthHigh impact
[Virginia] Precertification/prior authorization requirement changes
Anthem BCBS·VA · Oncology, Plastic Surgery, Wound Care +4 more·Provider Bulletin
Effective date
Dec 1, 2026
We identified it
Aug 6, 2026
Summary
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage (ISNP and CSNP plans) in Virginia will require prior authorization for 30 new procedure and supply codes, including prostate cancer screening, skin grafting procedures, esophageal procedures, neurolytic injections, wound care products, and durable medical equipment. Claims submitted without prior authorization for these codes will be denied as ineligible for payment.
Action Required
By November 1, 2026: Billing team must update billing system and workflow processes to require prior authorization through Anthem for all 30 affected codes when billing Medicare Advantage ISNP and CSNP members in Virginia. Specifically: (1) Configure billing software to flag claims with codes 0591U, 1044T-1049T, 43192, 43201, 43210, 43236, 43497, 43999, 64624, A2036-A2045, A4479, A9294, C1826, C1827, G0682, G0684, and L2221 for Anthem Medicare Advantage plans; (2) Instruct providers to submit prior authorization requests via Availity Essentials before scheduling or performing these procedures; (3) Update encounter forms and clinical workflows to require documented medical necessity; (4) Train front-desk and billing staff that claims lacking prior authorization will be denied as ineligible. Providers may appeal denials through Availity or by phone to Provider Services with supporting medical records.