CommercialCoverageHigh impact
[New York] Reimbursement policy reminder: Provider Preventable Conditions — Professional and Facility
Anthem BCBS·CT, GA, 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 deny reimbursement for all claims containing a Provider Preventable Condition (PPC) diagnosis code, specifically HAC01 (retention of a foreign object after surgery), including related services. The policy applies to professional and facility claims across multiple states. Providers are prohibited from balance billing members for denied claims under this policy.
Action Required
By September 30, 2026: Billing team must implement system controls to identify and flag claims containing HAC01 (retention of foreign object) and other Anthem-defined Provider Preventable Condition codes before submission. Update claim scrubbing software to prevent submission of claims with these diagnosis codes. Train all billing staff and providers on the never-event policy and prohibition against balance billing members. Establish internal audit procedures to review historical claims from October 1, 2026 forward, as Anthem reserves the right to recoup retroactively to the original October 1, 2026 effective date. Document all policy training and implementation steps. Contact Anthem for complete list of all defined PPC codes beyond HAC01.