Medicare AdvantagePrior AuthMedium impact
[California] Precertification/prior authorization requirement changes
Anthem BCBS·CA · Infectious Disease, Audiology, ENT (Ear, Nose & Throat) +2 more·Provider Bulletin
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Medicare Advantage plans in California will require prior authorization for 13 newly designated procedures and tests, including respiratory pathogen panels (CPT 0556U, 0563U, 0564U), totally implantable hearing implants (CPT 0951T-0955T), submucosal cryolysis therapy (CPT 0978T-0980T), gait modulation systems (HCPCS E3200), and atidarsagene autotemcel injection (HCPCS J3391). Claims submitted without prior authorization for these codes will be denied.
Action Required
By March 31, 2026: Billing team must update billing system and prior authorization workflows to require pre-approval from Anthem for all 13 affected codes when billing Medicare Advantage DSNP members in California. Update encounter forms and provider order entry templates to include alerts for codes 0556U, 0563U, 0564U, 0951T, 0952T, 0953T, 0954T, 0955T, 0978T, 0979T, 0980T, E3200, and J3391. Train providers and front desk staff to initiate prior authorization requests through Availity Essentials or by phone (number on member ID card) before services are rendered. Establish internal process to track and monitor prior auth status for these codes. Failure to obtain prior authorization will result in claim denials and potential patient balance liability.