CommercialPrior AuthHigh impact
[Virginia] May 2026 Provider Newsletter
Anthem BCBS·VA · Radiation Oncology, Orthopedics, Cardiology +2 more·Newsletter
We identified it
May 3, 2026
Summary
This is a comprehensive May 2026 provider newsletter from Blue Cross Blue Shield Virginia containing multiple policy updates across administrative, clinical, pharmacy, and reimbursement categories. Key changes include new prior authorization requirements effective at various dates through October 2026, specialty pharmacy updates, modifier 25 requirements for E&M with specific procedures, and updates to LTSS authorizations and clinical guidelines across multiple plan types.
Action Required
REQUIREMENTS:
1. By June 30, 2026: Hospitals with more than 50 beds must complete QHC compliance attestation. Contact compliance team to ensure submission deadline is met.
2. By July 1, 2026: Billing team must implement modifier 25 requirement for all XXX procedures billed with E&M services on Medicare Advantage plans. Update billing software to automatically flag and require modifier 25 on these claims to prevent denials.
3. By August 1, 2026: Review and implement specialty pharmacy updates and clinical criteria updates for Commercial plans. Coordinate with pharmacy and clinical teams to update prior authorization rules in the billing system.
4. By August 1, 2026: Implement new radiation oncology Carelon code updates and medical policy/UM guideline updates. Update internal coding references and staff training materials.
5. By September 1, 2026: Implement precertification/prior authorization requirement updates for musculoskeletal and radiation oncology services on Medicare Advantage plans. Update billing software to require prior auth for affected procedures.
6. By October 1, 2026: Implement prior authorization requirement updates for radiation oncology on Commercial plans effective October 1, 2026.
7. Immediate: For Medicaid claims, ensure National Drug Codes (NDCs) are included on all outpatient pharmacy claims. Update billing software to require NDC fields.
8. Before June 1, 2026: Medicaid providers must implement new PA and step therapy requirements for specialty drugs. Update prior authorization processes and staff training.
9. Before July 1, 2026: Update billing procedures for expanded specialty pharmacy precertification list on Medicare Advantage plans.
10. Ongoing: Verify C-SNP conditions with care providers on Medicare Advantage plans to prevent member disenrollment.
11. Ongoing: Update member ID card processing procedures to account for elimination of Suitcase Logo on BCBS cards.
12. For FEP members: Ensure medical records are submitted with genetic testing claims for review purposes.