MedicaidPrior AuthHigh impact
[New York] Precertification/prior authorization requirement changes
Anthem BCBS·NY · Wound Care, Plastic Surgery, General Surgery +3 more·Provider Bulletin
Effective date
Jan 1, 2027
We identified it
Oct 28, 2026
Summary
Effective January 1, 2027, Anthem will require prior authorization for 86 specific HCPCS and CPT codes covering advanced wound care matrices, skin substitutes, neurostimulator generators, and prosthetic components for New York Medicaid members. Claims submitted without required precertification may be denied. Providers can appeal denials through Availity Essentials or by phone with supporting clinical documentation.
Action Required
By January 1, 2027: Billing team must implement prior authorization requirements in the billing system for all 86 listed HCPCS and CPT codes for New York Anthem Medicaid members. Update encounter forms, superbills, and claim submission workflows to require precertification through Anthem before submitting claims for these codes. Train front-desk and clinical staff to request prior authorization before scheduling procedures using these codes. Consequence: Claims submitted without required prior authorization will be deemed ineligible for payment and denied.