CommercialPrior AuthHigh impact
[New York] March 2026 Provider Newsletter
Anthem BCBS·NY·Newsletter
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
This is a March 2026 provider newsletter from Anthem summarizing multiple administrative, educational, and policy updates across New York commercial, Medicare Advantage, and Medicaid plans. Key billing-related changes include: (1) Prior authorization requirement changes effective April 1, 2026 for Medicaid and June 1, 2026 for Commercial (codes 64595, J3402, J3403); (2) Modifier 26 (professional services) billing changes on UB-04 for outpatient facilities effective April 1, 2026; (3) Bundled services/supplies reimbursement policy updates effective June 1, 2026; (4) MCG Care Guidelines 30th edition updates effective June 1, 2026; and (5) New MLTC fax numbers and dispute submission process changes effective March 1, 2026.
Action Required
REQUIREMENTS:
Before April 1, 2026: Billing team must update systems to implement prior authorization requirement changes for CPT 64595 and HCPCS codes J3402 and J3403 on Commercial plans. Audit current claims for these codes and implement new prior auth workflows. Update provider encounter forms and internal billing guidelines.
Before April 1, 2026: Billing team must update UB-04 claim submission procedures for outpatient facility claims to properly apply modifier 26 (professional services). Review current facility billing templates and train billing staff on modifier usage. Failure to apply correct modifiers may result in claim denials or improper reimbursement.
Before June 1, 2026: Billing team must review and implement new MCG Care Guidelines 30th edition updates for all plan types (Commercial, Medicare Advantage, Medicaid). Update clinical documentation requirements and prior authorization criteria in billing system.
Before June 1, 2026: Billing team must update reimbursement procedures for bundled services and supplies on facility claims per new Commercial plan policy. Review affected service bundles and modify fee schedules accordingly.
Before March 1, 2026: Medicaid billing team must update MLTC dispute submission process to use Availity Essentials portal instead of fax. Update staff training and adjust new fax numbers for any remaining MLTC communications. Implement new submission procedures immediately to avoid processing delays.