CommercialCoverageHigh impact
[Ohio] Ensure inpatient facility claims have the correct primary diagnosis: non-reimbursable claims for unacceptable primary diagnosis (PDX) may require resubmission
Anthem BCBS·OH·Provider Bulletin
Effective date
Aug 1, 2026
We identified it
Jul 2, 2026
Summary
Effective August 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) will deny inpatient facility claims with unacceptable primary diagnosis codes as defined by CMS ICD-10-CM coding guidelines. Providers must ensure the primary diagnosis reflects the true reason for admission and is not a secondary diagnosis, or claims will be rejected and require resubmission.
Action Required
By July 31, 2026: Billing team and providers must implement a pre-submission review process for all inpatient facility claims to verify that the primary diagnosis (PDX) code is appropriate and reflects the principal reason for admission per CMS ICD-10-CM guidelines. (1) Update billing software or create manual checklist to flag claims with potentially unacceptable PDX codes before submission. (2) Train coding staff and providers to distinguish between appropriate primary diagnoses and secondary diagnoses. (3) Establish a process to identify denied claims with unacceptable PDX errors and resubmit corrected claims via Availity.com using the "correct a claim" function. (4) Reference CMS coding guidelines for acceptable PDX selection. Starting August 1, 2026, claims submitted with unacceptable primary diagnosis codes will be automatically denied and require corrected resubmission, resulting in payment delays and increased rework.