Back to dashboard
Medicare AdvantagePrior AuthHigh impact

[Virginia] Clinical Criteria updates

Anthem BCBS·VA · Oncology, Dermatology, Ophthalmology +9 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 has revised clinical criteria for 23 specialty pharmaceutical drugs and medical devices effective October 1, 2026, and added 4 new clinical criteria policies. These revisions affect medical necessity requirements and coding edits for high-cost injectable and infusion drugs used across multiple therapeutic areas including oncology, immunology, ophthalmology, and rare diseases. Billing teams must obtain the detailed clinical criteria documentation to understand specific authorization and documentation requirements for each affected drug.

Action Required

Before Oct 1, 2026
By September 30, 2026: (1) Billing and clinical staff must access Anthem's Clinical Criteria page to review the detailed requirements for all 27 affected clinical criteria policies (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). (2) Identify which specialty drugs your practice prescribes and obtain the specific clinical criteria requirements for each. (3) Update billing system workflows, prior authorization procedures, and clinical documentation requirements based on the revised criteria. (4) Alert providers and clinical staff about changes to medical necessity requirements for affected drugs; these revised policies may affect claim approvals and reimbursement. (5) Contact Anthem provider relations at the email address provided in the bulletin if authorization requirements are unclear. (6) Train front desk and billing staff on new documentation requirements. Failure to implement these changes by the effective date may result in claim denials for services that do not meet the new or revised clinical criteria.