CommercialPrior AuthHigh impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·OH · Gastroenterology, General Surgery, Internal Medicine·Provider Bulletin
Effective date
Feb 1, 2027
We identified it
Sep 24, 2026
Summary
Effective February 1, 2027, Anthem Blue Cross and Blue Shield (Ohio) is adding 21 esophagogastroduodenoscopy (EGD) procedure codes to the prior authorization/precertification requirement list through Carelon Medical Benefits Management. All EGD procedures—both transnasal and transoral approaches with various therapeutic interventions—will now require pre-authorization before service delivery to ensure alignment with current clinical guidelines and evidence-based coverage criteria.
Action Required
Before February 1, 2027: Billing team must update billing system and encounter templates to require prior authorization for all 21 EGD codes (0652T, 0653T, 0654T, and 43233-43270). Providers and clinical staff must obtain precertification through Carelon Medical Benefits Management via the provider portal (https://providerportal.com) or Availity Essentials (https://Availity.com) BEFORE scheduling or performing any EGD procedures. Update internal workflows, staff training, and order entry systems to flag these codes for mandatory authorization. Communicate this requirement to all ordering providers and endoscopy/gastroenterology staff. Failure to obtain prior authorization will result in claim denials from Anthem Blue Cross and Blue Shield Ohio commercial plans.