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[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
Act
by Nov 30, 2026
Effective date
Nov 30, 2026
Identified
Oct 28, 2026
Summary
HealthKeepers, Inc. (Anthem) is updating 26 medical policies and clinical utilization management guidelines for Virginia Medicaid members effective November 30, 2026. Changes include new policies for gene therapies, cellular immunotherapy, and cancer treatments, plus revisions to existing guidelines for procedures including breast surgery, deep brain stimulation, and various surgical/rehabilitation services. Some policy changes may result in services previously covered being classified as not medically necessary.
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What to do
by Nov 30, 2026 · 6 steps
01The billing and clinical team must review the updated Medical Policies and Clinical UM Guidelines on the HealthKeepers Medical Policies and Clinical UM Guidelines website to identify which procedures performed by this practice are affected.
02Specific actions include.
03Providers should verify prior authorization requirements for the 26 revised/new policies listed, particularly for gene therapies (hemophilia, beta thalassemia, hearing loss, Wiskott-Aldrich syndrome, leukocyte adhesion deficiency), cellular immunotherapy, tumor treatment field therapy, breast procedures, deep brain stimulation, cochlear implants, and cardiac/pulmonary rehabilitation.
04Billing team should update their prior authorization protocols and billing workflows in the practice management system to reflect any changed coverage or medical necessity criteria.
05Front desk and clinical staff should alert providers to review the policy summaries, as some previously covered services may now require additional justification or may be denied as not medically necessary.
06Verify current applicability by consulting the full policy text at the HealthKeepers provider website before submitting claims on or after the effective date.
Original notice
[Virginia] Medical Policies and Clinical Utilization Management Guidelines update
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Virginia] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Nov 1, 2026 · Prior Authorization[Virginia] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Oct 18, 2026 · Prior Authorization[Virginia] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Sep 28, 2026 · Prior Authorization[Virginia] Medical Policies and Clinical Utilization Management Guidelines updateMediumEffective Jun 19, 2026 · Prior AuthorizationBrowse every Anthem BCBS change in the policy list