CommercialAdministrativeHigh impact
[California] Review Excludes1 Notes to help keep claims on track
Anthem BCBS·CA·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Sep 2, 2026
Summary
Anthem Blue Cross (California) is implementing enhanced Excludes1 claim editing for ICD-10-CM diagnosis codes effective October 1, 2026. Billing teams must review Excludes1 Notes before submission to ensure diagnosis codes are not reported together in violation of ICD-10-CM standards. Claims with prohibited code combinations will be rejected and require correction or dispute with supporting documentation.
Action Required
By September 30, 2026: Billing team must implement pre-submission review of all diagnosis code combinations against ICD-10-CM Excludes1 Notes. (1) Train coders and billers to check Excludes1 Notes at both the category level (first 3 characters) and specific code level before claim submission. (2) Update billing software/EMR to flag prohibited diagnosis code combinations for manual review. (3) Establish a process to correct claims with Excludes1 violations before submission. (4) Document the review process for compliance. Starting October 1, 2026: All claims submitted must comply with Excludes1 editing rules. If a claim is rejected with an Excludes1 edit, first verify coding accuracy against ICD-10-CM guidelines. If the combination is correct per guidelines, submit a dispute through Availity.com with supporting documentation. Failure to comply will result in claim denials and increased rework.