CommercialCoverageHigh impact
[Georgia] Reimbursement policy reminder: Provider Preventable Conditions — Professional and Facility
Anthem BCBS·GA, CT, IN, KY, MO, NV, NH, NY, OH, WI·Claims & Billing
Effective date
Oct 1, 2026
We identified it
Jul 2, 2026
Summary
Effective October 1, 2026, Anthem will not reimburse professional provider and facility claims that include diagnosis codes for Provider Preventable Conditions (PPCs), specifically Hospital Acquired Conditions (HACs) including HAC01 (retention of foreign object after surgery). Providers are prohibited from balance billing members for non-reimbursed claims. The policy was originally announced with a delayed implementation; Anthem reserves the right to retroactively recoup payments to the originally announced effective date.
Action Required
By September 30, 2026: Billing team must implement system edits to identify and flag claims containing Never Event diagnosis codes and HAC01 codes before submission to Anthem. Update claim denial protocols and staff training to reflect non-reimbursement of these claims. Providers must stop balance billing members for denied claims related to this policy. Implement monitoring for retroactive recoupment activity from Anthem back to the originally announced effective date. Coordinate with clinical staff to ensure providers understand documentation requirements for indicating Provider Preventable Conditions using appropriate diagnosis codes. Review all pending and recently submitted claims for potential retroactive recoupment exposure.