Medicare AdvantagePrior AuthMedium impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·NY · Nephrology, Oncology·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Jun 13, 2026
Summary
Starting October 1, 2026, two specific genetic testing codes (0628U for kidney disease genetic testing and 0630U for breast cancer genetic profiling) will require prior authorization through Carelon Medical Benefits Management for Medicare Advantage plans in New York. Providers must obtain precertification before performing these tests or claims will likely be denied.
Action Required
Before October 1, 2026: Billing team must update system to require prior authorization for codes 0628U and 0630U through Carelon Medical Benefits Management. Update encounter forms and provider workflows to obtain precertification via Carelon provider portal (https://providerportal.com) or Availity Essentials before performing these genetic tests. Failure to obtain prior auth will result in claim denials.