Medicare AdvantageAdministrativeMedium 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 is continuing its DRG clinical and coding validation audit program through its Complex and Clinical Audit (CCA) team and external vendors including Ceris. Your practice should expect ongoing medical record requests and audit correspondence from Anthem and/or its designated vendor partners as part of routine DRG validation activities. The medical record request and audit review processes remain consistent with previous procedures.
Action Required
Effective immediately (July 23, 2026): Billing and clinical teams must be prepared to respond to medical record requests from Anthem's Complex and Clinical Audit (CCA) team and designated vendors (including Ceris) for DRG clinical and coding validation audits. Designate a staff member to track and manage incoming audit correspondence and medical record requests. Implement a tracking system to monitor requests from both Anthem and external vendors to minimize duplicate requests and ensure timely responses. Establish a process to flag and communicate any duplicate requests to your provider relationship management representative. Failure to respond promptly to legitimate medical record requests may result in claim denials or audit findings.