CommercialPrior AuthMedium impact
[Ohio] Carelon Medical Benefits Management, Inc. Code Update
Anthem BCBS·OH · Wound Care, Orthopedics, General Surgery +1 more·Provider Bulletin
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Carelon Medical Benefits Management (on behalf of Anthem Blue Cross and Blue Shield in Ohio) is adding 30 specific CPT and HCPCS codes to its prior authorization requirements. These codes primarily cover external tibial nerve stimulation devices and biologic/synthetic wound care matrices and grafts. Billing teams must update systems to require prior authorization for all claims using these codes for Ohio commercial members.
Action Required
Before April 1, 2026: Billing team must update the billing system to automatically flag all claims using the 27 specified HCPCS and CPT codes (A4545, E0736, E0737, C1832, Q4334, Q4335, A2030-A2035, C1763, Q4354-Q4367) as requiring prior authorization for Carelon/Anthem Blue Cross Blue Shield commercial plans in Ohio. Coordinate with providers and ensure ordering staff understand that all tibial nerve stimulation supplies, autografts, and biologic wound matrices now require authorization before service delivery. Implement workflow in billing software to route these codes to prior authorization team before claim submission. Configure system to submit authorization requests via Carelon's ProviderPortal (providerportal.com) or Availity Essentials (www.Availity.com). Failure to obtain prior authorization will result in claim denials and potential patient liability. Train billing and front desk staff immediately on the new requirements.