Medicare AdvantageCoverageHigh impact
[Ohio] New reimbursement policy: Critical Care to Home — Facility
Anthem BCBS·OH · Emergency Medicine, Critical Care·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Medicare Advantage will deny reimbursement for Critical Care services (CPT 99291/99292 with revenue code 045X) when members are discharged home from the emergency room. Billing teams must identify and reject these claim lines before submission, as balance billing members is prohibited.
Action Required
By March 31, 2026: Billing team must implement system edits to identify and flag claims where CPT 99291 and/or 99292 are billed with revenue code 045X for members discharged home (not admitted for Trauma or Observation). Configure billing software to deny or hold these claim lines for review before submission to Anthem. Update provider encounter forms and billing guidelines to document disposition status (discharged home vs. admitted). Train billing staff and providers on policy. Ensure compliance with balance billing prohibition—do not bill members for denied claim lines. Claims submitted without this edit will be denied by Anthem.