Medicare AdvantageCoverageHigh impact
[Virginia] New reimbursement policy: Critical Care to Home — Facility
Anthem BCBS·VA · Critical Care, Emergency Medicine·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Medicare Advantage will no longer reimburse Critical Care services (CPT 99291, 99292) billed with revenue code 045X when members are discharged home from the emergency room. Providers cannot balance bill members for these non-reimbursable services. Billing teams must identify and deny claims matching this scenario to avoid compliance issues.
Action Required
Before April 1, 2026: Billing team must update claims processing logic in billing software to flag and deny CPT 99291 and/or 99292 claims paired with revenue code 045X when the patient disposition is 'discharged home.' Update internal billing guidelines to prohibit balance billing for these denied claims. Train billing staff to recognize this scenario and explain non-reimbursability to providers. Review claims submitted on or after April 1, 2026 with this code combination and deny appropriately. Failure to implement this change will result in claims being submitted for denial by Anthem, causing compliance violations and revenue loss.