MedicaidCoverageHigh impact
[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
Anthem BCBS·VA · General Surgery, Cardiology, Cardiothoracic Surgery +8 more·Prior Authorization
Effective date
Oct 18, 2026
We identified it
Sep 17, 2026
Summary
HealthKeepers, Inc. (Anthem Medicaid in Virginia) has revised 4 Medical Policies and 15 Clinical UM Guidelines effective October 18, 2026. These updates may expand or restrict coverage criteria for wound healing products, cardiac devices, transplants, DME, lab testing, and surgical procedures. Some services previously covered may now be deemed not medically necessary, requiring immediate review of affected procedures.
Action Required
By October 18, 2026: (1) Billing team must obtain and review the full text for all 19 revised/new guidelines at the Medical Policies and Clinical UM Guidelines website (link provided in policy). (2) For each affected clinical area (wound care, cardiac devices, DME, labs, transplants, orthopedic braces, vascular procedures, wound products, cardiac monitors, apheresis, Mohs surgery, gastroenterology procedures, and hospice), verify current prior authorization requirements and coverage criteria against the new guidelines. (3) Update billing system workflows, prior auth rules, and denial protocols to reflect any changes to medical necessity determinations. (4) Brief all providers and clinical staff on policy changes, particularly for services that may transition from covered to non-covered status. (5) Flag all pending and recently-approved claims for these service categories for potential rework if coverage criteria changed. Failure to implement these updates before the effective date may result in claim denials and compliance violations for HealthKeepers/Anthem Medicaid members in Virginia.