CommercialAdministrativeMedium impact
[New York] Continued collaboration on DRG clinical and coding validation
Anthem BCBS·NY·Coding
Effective date
Jul 23, 2026
We identified it
Jul 29, 2026
Summary
Anthem Blue Cross and Blue Shield will continue conducting DRG clinical and coding validation audits through its Complex and Clinical Audit (CCA) team and designated external vendors (EXL and Ceris). Practices should expect ongoing medical record requests and audit correspondence from Anthem and/or its vendor partners. The review processes remain consistent, with efforts to minimize duplicate medical record requests.
Action Required
By July 23, 2026: Billing and clinical staff must establish procedures to efficiently handle medical record requests from Anthem's CCA team and designated vendors (EXL and Ceris) for DRG validation audits. Designate a point person or team to receive and respond to audit correspondence to ensure timely submission of requested records. Coordinate internally to avoid duplicate medical record compilation when possible. Update staff training to recognize legitimate audit requests from both Anthem directly and its authorized vendor partners. Ensure response protocols are documented and communicated to all relevant departments (billing, medical records, clinical coding). Failure to respond timely to legitimate medical record requests may result in audit delays, claim disputes, or compliance concerns.