ExchangeDocumentationMedium impact
[Georgia] EMR alerts aim to close gaps in care for Affordable Care Act members
Anthem BCBS·GA·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Anthem Blue Cross Blue Shield (Georgia) is implementing EMR alerts to identify care gaps for ACA plan members and encourage proactive follow-up visits and clinical assessments. Providers must ensure accurate documentation of chronic conditions and submit claims with high specificity coding to support ACA program compliance and risk adjustment reporting.
Action Required
Effective May 1, 2026: (1) Clinical staff must monitor EMR alerts for ACA plan patients with identified care gaps and schedule follow-up visits as appropriate. (2) Providers must document comprehensive clinical assessments for patients with chronic or previously documented conditions, ensuring all relevant clinical data and diagnoses are captured in the medical record. (3) Billing team must submit all claims for ACA plan members with the highest specificity of coding (use most specific ICD-10 diagnosis codes available) and include all relevant clinical documentation to support risk adjustment reporting. (4) If questions arise regarding alerts or coding requirements, contact Anthem's Commercial Risk Adjustment team at prospectiveteam@anthem.com. Failure to address care gaps and provide complete documentation may result in claim denials or non-compliance with ACA program requirements.