Medicare AdvantagePrior AuthHigh impact
[California] May 2026 Provider Newsletter
Anthem BCBS·CA · Radiation Oncology, Orthopedics, Pharmacy·Newsletter
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
This May 2026 California provider newsletter contains multiple policy updates across administrative, education, prior authorization, reimbursement, and pharmacy areas effective from June through September 2026. Key changes include: (1) Modifier 25 requirement for E&M services with XXX procedures (effective July 1, 2026 for Medicare Advantage); (2) Prior authorization updates for radiation oncology and musculoskeletal services through Carelon (effective September 1, 2026); (3) New proof of timely filing requirements for Medicaid (effective June 15, 2026); (4) Specialty pharmacy precertification list expansion (effective July 1, 2026 for Medicare Advantage); and (5) National Drug Codes (NDCs) required for outpatient Medicaid claims (effective April 20, 2026 - already in effect).
Action Required
REQUIREMENTS:
IMMEDIATE (by June 15, 2026): Billing team must update claims submission process for Medicaid to comply with new proof of timely filing reimbursement policy. Verify proof of timely filing documentation is attached to all Medicaid claims. Failure to include proof of timely filing may result in claim denials or payment reductions effective June 15, 2026.
By June 30, 2026: Hospitals with more than 50 beds must complete QHC (Qualified Health Plan) compliance attestation for Commercial plans. Contact compliance officer to ensure attestation is submitted. Missing deadline may result in loss of network status.
By July 1, 2026: (1) Billing team must update system to automatically append Modifier 25 to all E&M service claims when billed with XXX procedures for Medicare Advantage members. Update encounter forms and templates to flag this requirement for providers. (2) Update billing software to reflect specialty pharmacy precertification list expansion for Medicare Advantage claims; route affected medications through new precertification process. (3) Update inpatient sepsis and newborn DRG submission process to require full medical records attachment for all Medicaid claims. Claims without supporting medical records will be denied.
By August 1, 2026: Billing team must implement prior authorization and step therapy updates for medications billed under the medical benefit for Medicaid. Update formulary rules in billing system; route affected medications through new authorization process before claim submission.
By September 1, 2026: Update prior authorization requirements for radiation oncology and musculoskeletal procedures through Carelon Medical Benefits Management. Implement new precertification thresholds in billing system. Obtain prior authorizations before claim submission; claims submitted without required authorization will be denied.
ONGOING: (1) For FEP Commercial members receiving genetic testing, ensure medical records are attached to all genetic testing claims for medical review. (2) Ensure NDCs (National Drug Codes) are included on all outpatient pharmacy claims for Medicaid (this requirement is already effective as of April 20, 2026). (3) Verify C-SNP members' documented qualifying conditions with providers to prevent member disenrollment for Medicare Advantage.