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[California] Critical Care to Home: what care providers need to know
Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Jun 25, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross Medi-Cal will no longer reimburse Critical Care services (CPT 99291, 99292) billed with revenue code 045X when the member is discharged home. This change redefines Critical Care eligibility based on discharge status, requiring billing teams to identify and deny or redirect these claims. Trauma and Observation services remain reimbursable.
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What to do
by Sep 30, 2026 · 5 steps
01Billing team must implement system edits to identify and flag claims with CPT 99291 or 99292 billed with revenue code 045X paired with discharge status '01' (home) for Anthem Medi-Cal members.
02Configure billing software to automatically deny these claim lines or route them for manual review before submission.
03Update provider education materials and billing worksheets to clarify that Critical Care codes cannot be billed when patients are discharged home, even if acute care was provided in the emergency room.
04Train billing and coding staff on the distinction between Critical Care (non-reimbursable when discharged home), Trauma services, and Observation services (which remain reimbursable).
05Ensure providers understand the balance-billing prohibition for non-reimbursable codes.
If missed: Failure to implement these changes will result in claim denials and potential compliance issues with Anthem Medi-Cal.
Codes mentioned
9929199292
Original notice
[California] Critical Care to Home: what care providers need to know
providernews.anthem.com · Always check the source before changing claims.
Related changes
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