Medicare AdvantageAdministrativeMedium impact
[Virginia] Carelon Medical Benefits Management updates
Anthem BCBS·VA · Cardiology, Cardiothoracic Surgery, Gastroenterology·Provider Bulletin
Effective date
Nov 15, 2026
We identified it
Aug 29, 2026
Summary
Anthem Blue Cross and Blue Shield in Virginia is adopting Carelon Medical Benefits Management Clinical Appropriateness Guidelines effective November 15, 2026, for two procedures: Cardiovascular Catheter-Based Closure of Patent Foramen Ovale and Surgical Upper Gastrointestinal Endoscopy. Existing prior authorization requirements remain unchanged, but providers should monitor for future prior authorization updates that will be communicated separately.
Action Required
By November 15, 2026: Billing and clinical teams must review and download the updated Carelon Medical Benefits Management guidelines for (1) Cardiovascular Catheter-Based Closure of Patent Foramen Ovale and (2) Surgical Upper Gastrointestinal Endoscopy from the Anthem provider portal. Ensure providers and billing staff are familiar with the new clinical appropriateness criteria. No immediate billing system changes are required at this time, as existing prior authorization requirements have not changed. Monitor for future separate communications regarding any new prior authorization requirements that may be implemented for these services.