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[New York] Clinical Criteria updates
Act
by Nov 29, 2026
Effective date
Nov 29, 2026
Identified
Oct 25, 2026
Summary
Anthem has revised 60 clinical criteria policies for medical drug benefits under Medicare Advantage plans, effective November 29, 2026. These revised criteria may affect prior authorization requirements, medical necessity determinations, and billing for a broad range of specialty pharmaceuticals including biologics, oncology agents, and rare disease treatments. The practice should review the full policy text for each affected drug to understand specific changes to clinical coding edits and authorization rules.
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What to do
by Nov 29, 2026 · 5 steps
01Billing team and clinical staff must review the revised Clinical Criteria policies (CC-0001 through CC-0310 as listed) on Anthem's Clinical Criteria page to identify changes to medical necessity requirements and prior authorization rules.
02Verify which affected drugs are commonly prescribed in the practice and update billing workflows, EMR templates, and prior authorization submission processes accordingly.
03Contact Anthem via the provided email channel for clarification on specific authorization requirements, as the notice explicitly states that authorization rules are communicated separately.
04Ensure all providers and office staff are notified of the changes to prevent claim denials due to non-compliance with updated clinical coding edits.
05Retain this notice for reference and track which revised criteria apply to the practice's patient population and formulary usage.
Original notice
[New York] Clinical Criteria updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[New York] Clinical Criteria updates (November 2026 Newsletter)MediumNo effective date · Provider Bulletin[Virginia] Clinical Criteria updates (November 2026 Newsletter)LowNo effective date · Provider Bulletin[California] Clinical Criteria updates (November 2026 Newsletter)MediumNo effective date · Provider Bulletin[New York] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Nov 30, 2026 · Prior AuthorizationBrowse every Anthem BCBS change in the policy list