CommercialPrior AuthMedium impact
[New York] Carelon Medical Benefits Management, Inc. Code Update
Anthem BCBS·NY · 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 will require prior authorization for 30 specific HCPCS and CPT codes related to tibial nerve stimulators, autografts, and advanced wound care matrices. Billing teams must implement prior authorization workflows for these codes in their system and ensure providers submit requests through Carelon's ProviderPortal or Availity before delivering these supplies and services.
Action Required
By March 31, 2026: Billing team must update billing software and claim submission workflows to require prior authorization for all 27 affected HCPCS and CPT codes (A4545, E0736, E0737, C1832, Q4334, Q4335, A2030-A2035, C1763, Q4354-Q4367). Configure the system to flag these codes and block claims submission until prior authorization is obtained. Providers and office staff must be trained to submit prior authorization requests via Carelon's ProviderPortal (providerportal.com) or Availity (www.Availity.com) before ordering or servicing these supplies and grafts. Claims submitted without prior authorization will be denied. For authorization guideline questions, contact Carelon at MedicalBenefitsManagement.guidelines@Carelon.com.