Medicare AdvantagePrior AuthMedium impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·OH · Nephrology, Oncology·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Jun 13, 2026
Summary
Starting October 1, 2026, two new genetic testing codes (0628U for kidney disease-related genetic testing and 0630U for breast cancer gene expression profiling) will require prior authorization through Carelon Medical Benefits Management for Medicare Advantage plans in Ohio.
Action Required
Before October 1, 2026: Billing team must update prior authorization workflows to require precertification for codes 0628U and 0630U through Carelon Medical Benefits Management. Set up system alerts in billing software for these codes. Train staff to submit authorization requests via Carelon provider portal at https://providerportal.com or through Availity Essentials. Claims without prior auth will be denied.