CommercialAdministrativeHigh impact
[New York] Updated claims editing process for outpatient facility claims
Anthem BCBS·NY·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Aug 4, 2026
Summary
Effective October 1, 2026, Anthem will implement the CMS Outpatient Code Editor (NCCI) for front-end claims editing on outpatient facility claims. This means claims with coding errors—particularly procedure-to-procedure conflicts like mutually exclusive or component procedures—will be denied at adjudication rather than undergoing back-end review. Billing teams must ensure outpatient facility claims follow strict NCCI coding guidelines to avoid claim denials.
Action Required
By September 30, 2026: (1) Billing team must review CMS NCCI Procedure-to-Procedure (PTP) edits at https://www.cms.gov to identify mutually exclusive procedures and component procedures applicable to your outpatient facility claims. (2) Update coding protocols and billing software validation rules to flag potential NCCI conflicts before claim submission. (3) Educate providers and coding staff on NCCI guidelines, particularly around procedure-to-procedure editing rules. (4) Audit recent outpatient facility claims for coding patterns that may conflict with NCCI edits and proactively correct claims before October 1. (5) Establish a process to monitor claim denials post-October 1 for NCCI-related rejections and file disputes through Anthem's standard claim dispute process if coding was correct. Failure to comply will result in increased claim denials and delayed reimbursement for outpatient facility services.