Medicare AdvantageBilling CodesHigh impact
[California] September 2026 Provider Newsletter
Anthem BCBS·CA·Newsletter
We identified it
Sep 2, 2026
Summary
This September 2026 provider newsletter from Anthem Blue Cross contains multiple policy updates across billing codes, prior authorization, reimbursement, and administrative processes. Key changes include: modifier 25 billing requirements for E&M services with XXX procedures (effective Oct 1, 2026 for Medicaid), blood product administration billing consolidation (effective Dec 1, 2026), new laboratory service modifier policies (effective Dec 1, 2026), and treatment room reimbursement updates (effective Dec 1, 2026). The newsletter also announces Medicaid 2027 work requirements effective January 1, 2027, and various administrative updates across plan types.
Action Required
MULTIPLE EFFECTIVE DATES - Immediate review required:
By October 1, 2026: Billing team must update Medicaid billing protocols to require modifier 25 when billing eligible E&M (Evaluation & Management) services with XXX-status procedures. Update billing software validation rules and provider education materials. Claims submitted without proper modifier 25 application will be denied.
By December 1, 2026: (1) Stop billing blood product administration services separately under Medicaid. Consolidate into primary procedure billing. Update all charge capture systems and billing templates. (2) Implement new combined reimbursement policy for modifiers 90 and 91 for laboratory services across Medicare Advantage and Medicaid. Update billing software to recognize new modifier guidelines. (3) Prepare and implement treatment room reimbursement updates for Medicaid. Verify facility coding changes in billing system. Test workflows before effective date.
Before October 1, 2026: Billing team must review and implement Excludes1 note updates for Commercial plans to prevent claim denials.
Immediate (Ongoing): Implement Carelon Medical Benefits Management updates effective September 28, 2026 (Medicare Advantage) and November 28, 2026 (Medicaid). Prior authorization and clinical appropriateness guideline changes require system updates. Review precertification/prior authorization requirement changes for Medicare Advantage effective September 28, 2026.
By January 1, 2027: Ensure all Medicaid claim processing systems account for new 2027 work requirement rules and documentation needs.
Other Administrative: Front desk and credentialing staff should utilize new Quick Contact Guide and Availity Essentials provider enrollment features. Complete required 2026 consumer grievance and appeals attestation survey for Commercial plans.