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[Ohio] National accounts: 2027 standard prior authorization requirements
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 23, 2026
Summary
Anthem Blue Cross and Blue Shield is updating prior authorization (PA) requirements for Ohio-based commercial accounts, effective January 1, 2027. The policy establishes comprehensive PA requirements across inpatient admissions, advanced diagnostic testing, DME/prosthetics, transplants, gene therapies, CAR T-cell treatments, mental health services, and numerous surgical procedures. Billing teams must implement these PA requirements in their workflows and systems before the effective date.
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What to do
by Jan 1, 2027 · 10 steps
01Billing team must implement prior authorization requirements for Anthem Blue Cross and Blue Shield Ohio commercial accounts across all listed service categories.
02Update billing system workflows to require pre-certification for all inpatient admissions (acute inpatient, acute rehab, LTACH, skilled nursing, OB deliveries beyond Federal mandate minimum), diagnostic testing (chromosomal microarray, genetic testing, hereditary cancer testing, genetic liquid biopsy, PFAS testing, prostate saturation biopsy, somatic tumor testing, Alzheimer's biomarkers, whole genome/exome sequencing, gene panels, molecular profiling, wireless capsule endoscopy), DME/prosthetics (AAC devices, brain-computer interfaces, compression devices, electrical stimulation devices, robotic rehabilitation systems, infusion pumps, prosthetic devices, bone stimulation devices, pneumatic compression, powered exoskeletons, and powered mobility devices), gender-affirming surgery (if covered), organ and bone marrow/stem cell transplants, CAR T-cell immunotherapy treatments, gene replacement therapies, mental health/substance abuse services (acute inpatient, TMS, residential care, in-home behavioral health, ABA, IOP, PHP), and extensive surgical services (bariatric surgery, cardiac procedures, vascular interventions, implantable devices, ENT procedures, orthopedic procedures, and others as listed).
03Configure the system to flag claims requiring PA before submission.
04Establish pre-certification submission protocols with Anthem.
05Train front desk, clinical, and billing staff on new PA requirements.
06Update encounter forms and patient communications to reflect new PA needs.
07Emergency care admissions are exempt from pre-certification but require plan notification as soon as possible.
08ABA pre-certification is recommended and applies unless the group specifically opts out of clinical review.
09Claims submitted without required prior authorization will be subject to denial.
10Front-line staff should verify coverage and obtain authorizations before scheduling or treatment when applicable.
Original notice
[Ohio] National accounts: 2027 standard prior authorization requirements
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Ohio] Precertification/prior authorization requirement changesMediumEffective Mar 1, 2027 · Provider Bulletin[Ohio] New prior authorization requirementsMediumEffective Jan 1, 2027 · Provider Bulletin[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management (November 2026 Newsletter)MediumEffective Feb 1, 2027 · Provider Bulletin[Ohio] Quick guide to services requiring prior authorization — updatedHighEffective Oct 26, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list
Related policy hubs
Anthem BCBS policiesOH policy changesCardiologyCardiothoracic SurgeryDermatologyENT (Ear, Nose & Throat)GastroenterologyGeneral SurgeryGeneticsHematologyNeurologyNeurosurgeryOB-GYNOncologyOphthalmologyOral & Maxillofacial SurgeryOrthopedicsPain ManagementPlastic SurgeryPM&R (Physical Medicine & Rehab)PsychiatryPulmonologySpeech TherapyTransplant SurgeryUrologyVascular SurgeryWound Care