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[Ohio] Review Excludes1 coding before submitting claims
Effective date
Dec 1, 2026
Identified
Oct 21, 2026
Summary
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) will apply ICD-10-CM Excludes1 Notes editing to inpatient and outpatient claims for medical and behavioral health services on Medicare Advantage plans. Billing teams must review diagnosis coding for conflicting code combinations before claim submission; claims with unresolved Excludes1 conflicts will be denied and require correction and resubmission.
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What to do
Action · 6 steps
01Before December 1, 2026: Billing team must review all diagnosis coding workflows and ICD-10-CM Excludes1 guidance applicable to the practice's patient populations.
02For each claim submitted on or after the effective date, coders and billing staff must verify that reported diagnosis code combinations comply with ICD-10-CM Excludes1 Notes—especially for complex inpatient claims with multiple diagnoses—to ensure codes reflect the member's clinical condition and are reported to appropriate specificity.
03Update claim submission procedures to require Excludes1 verification before claims are transmitted to Anthem.
04Failure to address Excludes1 conflicts will result in claim denial; denied claims will need correction and resubmission, causing payment delays.
05Staff should familiarize themselves with the dispute resolution process outlined in the Anthem Provider Manual in case claim decisions need to be challenged.
06Contact Anthem's Availity Chat (during business hours) or the Contact Us section of the provider website for questions about the edit or specific code combinations.
Original notice
[Ohio] Review Excludes1 coding before submitting claims
providernews.anthem.com · Always check the source before changing claims.
Related changes
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