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[California] Help support accurate inpatient claims with the correct primary diagnosis
Effective date
Jan 1, 2027
Identified
Oct 21, 2026
Summary
Effective January 1, 2027, Anthem Blue Cross will enforce stricter review of inpatient facility claims to ensure the primary diagnosis code reflects the actual primary reason for admission and complies with CMS coding guidelines. Claims submitted with unacceptable primary diagnosis codes will be denied and require corrected claim submission; no balance billing of members is permitted.
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What to do
Action · 7 steps
01Beginning January 1, 2027: Billing team must review and validate all inpatient facility claims before submission to ensure the primary diagnosis code reflects the primary reason for admission and meets CMS coding guidelines.
02Implement a pre-submission audit process in the billing system to flag claims with potentially unacceptable primary diagnosis codes.
03Train coding and billing staff on current CMS guidelines for acceptable primary diagnosis coding.
04Establish a corrected claim workflow using Anthem's Availity portal (https://Availity.com) for resubmission of denied claims.
05Ensure providers understand that non-compliant claims will not be reimbursed and members may not be balance billed.
06Monitor claim status and denials related to primary diagnosis coding through Availity's Claims Status tool.
07If disputes arise, follow Anthem's standard claim dispute process.
Original notice
[California] Help support accurate inpatient claims with the correct primary diagnosis
providernews.anthem.com · Always check the source before changing claims.