Medicare AdvantagePrior AuthHigh impact
[California] Precertification/prior authorization requirement changes
Anthem BCBS·CA · Oncology, Plastic Surgery, Gastroenterology +4 more·Provider Bulletin
Effective date
Dec 1, 2026
We identified it
Aug 7, 2026
Summary
Effective December 1, 2026, Anthem Blue Cross Medicare Advantage plans in California are adding prior authorization requirements for 30 specific procedure and supply codes, including prostate cancer screening (0591U), skin graft procedures (1044T-1049T, G0682, G0684), esophageal procedures (43192, 43201, 43210, 43236, 43497), neurolytic injections (64624), wound care matrices, neurostimulator generators, and orthotic devices. Claims submitted without prior authorization for these codes may be denied as ineligible for payment.
Action Required
By November 30, 2026: Billing team must update billing software and prior authorization workflows to require precertification from Anthem Blue Cross for all 31 affected CPT, HCPCS, and device codes listed above for California Medicare Advantage HMO members. Specifically: (1) Configure the billing system to flag these codes for mandatory prior authorization submission; (2) Update provider encounter forms and templates to alert clinicians when these procedures are being billed; (3) Establish process for obtaining prior authorization through Availity Essentials or Provider Services phone line before claim submission; (4) Train front desk and coding staff on new requirements. Failure to obtain prior authorization prior to service delivery or claim submission will result in claim denials and may be deemed ineligible for payment. Providers may appeal denials by submitting additional medical records through Availity Essentials or by phone.