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[Georgia] Clinical Criteria updates

Anthem BCBS·GA · Allergy & Immunology, Dermatology, Endocrinology +8 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Aug 27, 2026
Days to comply
16 days

Summary

Anthem Blue Cross and Blue Shield (Georgia) has revised 23 clinical criteria policies for specialty medications and medical devices, effective October 1, 2026. Four new clinical criteria have been added for recently FDA-approved drugs. These changes may affect medical necessity requirements, coding edits, and prior authorization processes for specialty pharmaceutical and biologic treatments covered under the medical drug benefit.

Action Required

Before Oct 1, 2026
By September 15, 2026: Billing team and clinical staff must obtain the full text of all 27 revised and new clinical criteria from Anthem's Clinical Criteria page (reference numbers CC-0029, CC-0031, CC-0032, CC-0043, CC-0057, CC-0061, CC-0077, CC-0099, CC-0112, CC-0119, CC-0121, CC-0125, CC-0128, CC-0130, CC-0151, CC-0158, CC-0163, CC-0218, CC-0237, CC-0243, CC-0258, CC-0276, CC-0279, CC-0281, CC-0303, CC-0304, CC-0305, CC-0306). Review each document to identify any changes to medical necessity requirements or coding edits that may impact claims submission. Update billing system rules, prior authorization workflows, and clinical documentation templates accordingly. Contact Anthem directly via the provided email for clarification on authorization requirements, which will be communicated in a separate notice. Ensure providers and front-desk staff are informed of changes affecting their specialty. Failure to comply with updated clinical criteria may result in claim denials for non-compliance with medical necessity requirements.
[Georgia] Clinical Criteria updates | Anthem BCBS | PolicyChanges.app