CommercialReimbursementHigh impact
[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility policy
Anthem BCBS·OH·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem (Ohio) is updating facility reimbursement guidelines requiring specific modifiers (PN, PO, ER) on outpatient claims billed on CMS-1500 forms rather than UB-04 forms. Off-campus provider-based services not contracted with the hospital will be reimbursed at only 40% of allowable when modifier PN is used, while contracted off-campus departments and emergency departments require modifiers PO and ER respectively.
Action Required
By March 15, 2026: Billing team must implement the following changes: (1) Update billing system to append modifier PN to all outpatient professional services provided at off-campus locations NOT contracted as part of hospital agreements, resulting in 40% payment reduction; (2) Append modifier PO to services at contracted off-campus provider-based outpatient departments; (3) Append modifier ER to off-campus provider-based emergency department services; (4) Switch from UB-04 (institutional) to CMS-1500 (professional) form submission for these claims to ensure correct reimbursement; (5) Train all billing and front-desk staff on new modifier requirements and location-based billing rules. Update encounter forms and provider documentation templates to capture service location details necessary for correct modifier assignment. Failure to apply correct modifiers and use CMS-1500 forms will result in claim denials or reduced payment at 40% of allowable.