CommercialReimbursementHigh impact
[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility policy
Anthem BCBS·GA·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Georgia will no longer reimburse professional services billed on UB-04 forms. Outpatient claims must now use modifiers PN, PO, or ER to indicate service location, with modifier PN services (off-campus, non-contracted) reimbursed at 40% of allowable. This requires immediate billing workflow updates to ensure correct modifier application and payment.
Action Required
By March 31, 2026: Billing team must update billing software to prohibit UB-04 submission for professional services under Anthem Georgia commercial plans. For all outpatient claims effective April 1, 2026: (1) Append modifier PN to services at off-campus locations NOT under hospital agreement (expect 40% reimbursement reduction); (2) Append modifier PO to services at off-campus provider-based outpatient departments contracted under hospital agreement; (3) Append modifier ER to off-campus emergency department services. Update encounter forms and billing templates to require modifier selection based on service location. Train billing staff and providers on modifier requirements. Notify all providers that claims submitted without appropriate modifiers or on UB-04 forms will be denied or face payment reductions. Verify hospital contract status for all off-campus locations to ensure correct modifier assignment.