Medicare AdvantagePrior AuthHigh impact
[Ohio] Precertification/prior authorization requirement changes
Anthem BCBS·OH · Oncology, Gastroenterology, Dermatology +4 more·Provider Bulletin
Effective date
Jan 1, 2027
We identified it
Aug 6, 2026
Summary
Effective January 1, 2027, Anthem Blue Cross and Blue Shield is adding prior authorization requirements for 42 billing codes across multiple specialties for MyCare Ohio Fully Integrated Dual Eligible (FIDE) plans. These codes include oncology testing (0591U), skin graft procedures (1044T-1049T, Q4383-Q4397, A2036-A2045, G0682-G0684), esophageal procedures (43192, 43201, 43210, 43236, 43497), and other advanced treatments. Claims submitted without prior authorization may be denied for payment.
Action Required
By December 31, 2026: Billing team must implement prior authorization requirements in all billing systems and practice management software for all 42 affected codes when billing MyCare Ohio FIDE members. Update encounter forms, order entry workflows, and EMR templates to flag these codes for prior auth review before submission. Train providers and front desk staff to identify affected codes and initiate prior authorization requests through Availity Essentials or by calling Anthem Provider Services at 833-727-2170. Establish verification process to confirm prior auth approval before claim submission. Beginning January 1, 2027, do NOT submit claims for these codes without documented prior authorization approval. Failure to obtain prior authorization will result in claim denials and potential non-payment for services rendered.