Medicare AdvantageAdministrativeMedium impact
[California] Carelon Medical Benefits Management updates
Anthem BCBS·CA · Cardiology, Gastroenterology·Provider Bulletin
Effective date
Sep 28, 2026
We identified it
Aug 28, 2026
Summary
Anthem Blue Cross is transitioning to Carelon Medical Benefits Management Clinical Appropriateness Guidelines effective September 28, 2026, with two specific guidelines (Cardiovascular Catheter-Based Closure of Patent Foramen Ovale and Surgical Upper Gastrointestinal Endoscopy) publishing November 15, 2026. Existing prior authorization requirements remain unchanged, but practices must review and implement the new clinical guidelines and monitor for future prior authorization requirement notices.
Action Required
By September 28, 2026: Billing and clinical teams must download and review the Carelon Medical Benefits Management Clinical Appropriateness Guidelines from the Anthem provider portal. By November 15, 2026: Review the two updated guidelines (Patent Foramen Ovale Catheter-Based Closure and Surgical Upper Gastrointestinal Endoscopy) and update clinical protocols and documentation requirements accordingly. All staff should monitor for a separate notice regarding any new prior authorization requirements that may be implemented for these services. Share this bulletin with all clinical and billing staff. No immediate billing system changes are required at this time, but proactive review of guidelines is essential to ensure compliance.