MedicaidDocumentationHigh impact
[California] Enhancing claims accuracy: new process for inpatient sepsis and some newborn DRG submissions with full medical records
Anthem BCBS·CA · Critical Care, Pediatrics, Infectious Disease·Coding
Effective date
Jul 1, 2026
We identified it
May 28, 2026
Summary
Effective July 1, 2026, Anthem Blue Cross (Medi-Cal Managed Care in California) will require complete medical records to be submitted with inpatient sepsis and certain newborn DRG claims at the time of initial submission to validate correct DRG assignment. Claims submitted without medical records may not be eligible for reimbursement until records are provided. Normal newborn MS DRG 795 and APR DRG 640-1 are excluded from this requirement.
Action Required
By June 30, 2026: Billing team must implement the following changes for all inpatient sepsis and newborn claims (excluding MS DRG 795 and APR DRG 640-1) submitted to Anthem Blue Cross Medi-Cal Managed Care in California: (1) Register facility for Availity Essentials and Medical Attachments application if not already registered at https://Availity.com; (2) Update claim submission workflow to require complete medical records attached to initial claim filing; (3) For Epic EMR users, contact emrintegration@carelon.com to configure automatic digital EMR sharing; (4) For non-digital records, establish process to submit through Availity Essentials; (5) Train billing and clinical staff on new submission requirements and digital attachment workflows using Learning Hub training resources. Consequences: Claims submitted without required medical records will not be eligible for reimbursement until records are provided, and claims will be reviewed prior to payment or audited after payment. Billing team responsible for implementing system changes and monitoring compliance.