Summary
This October 2026 Ohio provider newsletter contains multiple policy updates effective January 1, 2027, and November 1, 2026, affecting claims submission, prior authorization requirements, E/M documentation, maternity coding, and medical records handling across Commercial, Medicare Advantage, and Medicaid plans. Key changes include mandatory electronic claims submission (to avoid paper handling fees), expanded inpatient DRG submissions with full medical records, new E/M service requirements, maternity services coding changes, and prior authorization process modifications.
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What to do
Action · 24 steps
01REQUIREMENTS:
IMMEDIATE (October 2026):
- Billing team must transition all claims to no-cost electronic submission to avoid new paper handling fees.
02Update billing software settings and provider submission workflows.
03Implement compliance monitoring.
04Paper claims will incur new handling fees effective immediately.
05- All staff must respond promptly to medical record audit requests from Medicare Advantage plans to avoid potential compliance issues and contract penalties.
06BY NOVEMBER 1, 2026:
- Billing team and providers must review and implement new E/M service requirements for Commercial plans.
07Update encounter forms, clinical documentation templates, and billing rules in the system.
08Ensure providers understand new documentation standards.
09Non-compliant claims may be denied or delayed.
10BY JANUARY 1, 2027:
- Billing team must update system to require full medical records submission with all high-impact inpatient DRG cases for Commercial and Medicare Advantage plans.
11Modify claim submission workflows and establish medical records attachment protocols.
12Train staff on new DRG submission requirements.
13- Billing team must implement maternity services coding changes for Commercial and Medicaid plans.
14Review and update all maternity-related CPT/HCPCS code mappings in billing software.
15Update claim edit rules and coder training materials.
16- Billing team must implement prior authorization requirement changes for Medicare Advantage and Medicaid plans (per Carelon Medical Benefits Management and standard requirements).
17Update system authorization rules, obtain updated authorization matrices, and train staff on new processes.
18Failure to obtain required prior authorizations will result in claim denials.
19- Billing team must implement post-acute care authorization process changes for MyCare Ohio (Medicaid).
20Update referral and authorization workflows for skilled nursing, assisted living, and rehabilitation services.
21- Billing team must implement new Ordering, Rendering, and Prescribing (ORP) provider requirements for Medicaid/MyCare Ohio.
22Update credentialing documentation and system configurations.
23- Billing and coding team must ensure Present on Admission (POA) indicators are accurately checked and reported on all Medicaid claims to support accurate processing and reimbursement.
24- All clinical and billing staff should verify practice information in the provider directory across all plan types (Commercial, Medicare Advantage, Medicaid, MyCare Ohio) to ensure members can locate the practice.
Original notice
[Ohio] October 2026 Provider Newsletter
providernews.anthem.com · Always check the source before changing claims.