CommercialReimbursementHigh impact
[Ohio] Outpatient facility claims update: modifier 26 (professional services) on UB‑04
Anthem BCBS·OH·Provider Bulletin
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem will no longer allow separate facility reimbursement on outpatient facility claims when modifier 26 (professional services) is appended. Billing teams must stop expecting dual reimbursement for these lines and align claims with Anthem's Facility Guidelines for Claims Related to Professional Services policy. Claims processed on or after this date with modifier 26 will not receive separate facility payment.
Action Required
By March 31, 2026: Billing team must update billing system edits and claim submission procedures to flag or prevent submission of outpatient facility claim lines with modifier 26 expecting separate facility reimbursement. Review all standing orders, encounter templates, and fee schedules to identify procedures commonly billed with modifier 26 on UB-04 forms and adjust expected reimbursement accordingly. Train billing staff that modifier 26 on outpatient facility claims will not generate separate facility payment starting April 1, 2026. Implement process to identify claims that may have been incorrectly processed after the effective date and route them through Anthem's claim dispute process for review and adjustment per their guidance.