CommercialCoverageHigh impact
[Georgia] New reimbursement policy: Critical Care to Home — Facility
Anthem BCBS·GA · Emergency Medicine, Critical Care·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 14, 2026
Summary
Effective April 1, 2026, Anthem will no longer reimburse Critical Care services (CPT 99291 with revenue code 045X) when billed in the emergency department for members discharged home. These services are now considered non-reimbursable unless the member requires inpatient admission, trauma, or observation services. Providers may not balance bill members for these denied claims.
Action Required
By March 31, 2026: Billing team must implement system edits to deny or flag claims with CPT 99291 and revenue code 045X when member discharge status is 'home' for Anthem Georgia commercial plans. Update billing software logic to automatically route these claims as non-reimbursable. Train all clinical and billing staff that CPT 99291 with revenue 045X for discharged-home patients will not be reimbursed and cannot be balance billed. Verify that CPT 99292 (Critical Care follow-up) continues to process normally. Update claim submission templates and provider documentation requirements to clarify when Critical Care is reimbursable (inpatient admission, trauma, observation only). Establish internal audit process to monitor for compliance and prevent balance billing violations. Contact affected providers in Georgia with notice of policy change and billing requirements.