CommercialAdministrativeHigh impact
[New York] Ensure inpatient facility claims have the correct primary diagnosis: non-reimbursable claims for unacceptable primary diagnosis (PDX) may require resubmission
Anthem BCBS·NY·Provider Bulletin
Effective date
Aug 1, 2026
We identified it
Jul 2, 2026
Summary
Effective August 1, 2026, Anthem will deny inpatient facility claims that list an unacceptable primary diagnosis code (as defined by CMS ICD-10-CM guidelines) and require corrected claim resubmission. Billing teams must validate that the primary diagnosis reflects the true reason for admission and is not a secondary condition before claim submission.
Action Required
Before August 1, 2026: (1) Billing team must implement a validation step in the claim submission workflow to verify inpatient primary diagnosis codes are acceptable per CMS ICD-10-CM coding guidelines before submission. (2) Update claim scrubbing rules in billing system to flag and reject claims with unacceptable PDX codes before transmission to Anthem. (3) Train providers and coders on proper PDX sequencing—ensure the first-listed diagnosis reflects the primary reason for admission, not secondary conditions. (4) Create reference documentation for staff identifying common unacceptable PDX codes per CMS guidelines. (5) Establish corrected claim resubmission process: staff must use Availity.com portal (Help & Training → Find Help → search 'correct a claim') to resubmit denied claims with corrected PDX. (6) Monitor claim denials for PDX-related rejections and flag trends to providers. Consequence: Claims with unacceptable primary diagnosis codes will be denied and will not be reimbursed until a corrected claim is submitted.