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[New York] Clinical Criteria updates

Anthem BCBS·NY · Oncology, Allergy & Immunology, Hematology +8 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Aug 29, 2026
Days to comply
16 days

Summary

Anthem has revised 46 clinical criteria policies for specialty drugs and biologic agents effective October 1, 2026. These revisions update medical necessity requirements for high-cost injectable and infused medications across oncology, immunology, rare disease, and other specialties. The practice must review updated clinical criteria documentation for each affected drug to ensure claims comply with new authorization and medical necessity standards.

Action Required

Before Oct 1, 2026
By September 30, 2026: Billing and clinical teams must access Anthem's Clinical Criteria portal to review all 46 revised policies (CC-0002, CC-0010, CC-0024, CC-0027, CC-0029, CC-0033, CC-0034, CC-0042, CC-0043, CC-0048, CC-0051, CC-0063, CC-0072, CC-0075, CC-0087, CC-0092, CC-0094, CC-0101, CC-0102, CC-0105, CC-0106, CC-0107, CC-0108, CC-0111, CC-0114, CC-0116, CC-0124, CC-0128, CC-0130, CC-0143, CC-0145, CC-0153, CC-0158, CC-0160, CC-0162, CC-0165, CC-0166, CC-0167, CC-0169, CC-0175, CC-0188, CC-0201, CC-0206, CC-0207, CC-0209, CC-0225, CC-0240, CC-0252, CC-0262, CC-0264, CC-0274, CC-0276, CC-0284, CC-0285, CC-0294, CC-0299, CC-0302). Identify any changes to medical necessity requirements for drugs commonly prescribed in your practice. Update prior authorization processes, encounter forms, and clinical documentation templates to align with new criteria. Communicate changes to all prescribing providers and billing staff. Failure to comply with updated criteria will result in claim denials for non-compliant submissions after October 1, 2026.