Medicare AdvantagePrior AuthHigh impact
[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·CA · Dermatology, Plastic Surgery, Gastroenterology +2 more·Provider Bulletin
Effective date
Jan 1, 2027
We identified it
Sep 25, 2026
Summary
Effective January 1, 2027, Anthem Blue Cross Medicare Advantage PPO plans in California will require precertification/prior authorization through Carelon Medical Benefits Management for 73 specific billing codes related to skin grafts, esophageal procedures, dermal matrices, neurostimulator generators, and skin substitutes. Billing teams must implement prior authorization requirements in their systems before this date to avoid claim denials.
Action Required
By December 31, 2026: Billing team must update all billing and claims management systems to require prior authorization through Carelon Medical Benefits Management for all 73 affected codes (skin graft procedures 1044T-1049T, esophageal procedures 43192/43201/43210/43236/43257/43497, dermal matrices A2036-A2045, neurostimulator generators C1826-C1827, skin substitutes G0681-G0684, and wound care matrices Q4182 and Q4368-Q4423). Update provider encounter forms and templates to include prior authorization reminders for these procedures. Configure system workflows to block claims submission without evidence of approved prior authorization for California Anthem Blue Cross Medicare Advantage PPO patients. Communicate requirements to all providers, surgical centers, and clinical staff. Claims submitted for these codes without prior authorization will be denied, resulting in payment delays and potential patient liability.