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Medicare AdvantagePrior AuthHigh impact

[Georgia] Medical Policies and Clinical Utilization Management Guidelines update

Anthem BCBS·GA · Cardiology, Cardiothoracic Surgery, Vascular Surgery +10 more·Prior Authorization
Effective date
Sep 28, 2026
We identified it
Aug 27, 2026
Days to comply
13 days

Summary

Anthem Blue Cross Blue Shield (Georgia) is updating 19 Medical Policies and Clinical Utilization Management Guidelines effective September 28, 2026. These revisions affect coverage criteria for cardiac devices, diabetes management equipment, laboratory testing, surgical procedures, and other services. Some policy changes may result in previously covered services being deemed not medically necessary, requiring immediate review of affected procedures and prior authorization workflows.

Action Required

Before Sep 28, 2026
By September 27, 2026: (1) Billing team must access the full policy text for each guideline listed (SURG.00011, SURG.00032, SURG.00121, TRANS.00008, CG-DME-42, CG-DME-44, CG-DME-50, CG-LAB-21, CG-LAB-37, CG-LAB-38, CG-MED-101, CG-MED-40, CG-MED-68, CG-OR-PR-02, CG-SURG-106, CG-SURG-126, CG-SURG-127, CG-SURG-131, CG-SURG-132, CG-SURG-133, CG-SURG-90, CG-TRANS-04) at the Anthem Medical Policies and Clinical UM Guidelines website to identify specific CPT/HCPCS code impacts and prior authorization requirements. (2) Update billing system rules and prior authorization workflows for all revised and new guidelines. (3) Identify high-volume procedures (cardiac valve repairs, continuous glucose monitoring, insulin delivery systems, wound healing products, braces, apheresis) and prioritize policy review for these first. (4) Communicate changes to clinical staff, coding team, and providers via department meeting and written notice before September 28, 2026. (5) Flag all claims for affected procedures submitted after September 28, 2026 for manual review against new medical necessity criteria to prevent denials. Failure to implement prior auth changes and medical necessity criteria will result in claim denials.

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