CommercialAdministrativeHigh impact
[New York] New Commercial Facility Administrative Policy: Use of a Nonparticipating Care Provider
Anthem BCBS·NY·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem will penalize participating facilities in New York that use nonparticipating care providers in facility-based settings (inpatient or outpatient) by imposing a 7.5% administrative penalty on facility claims and risk of network termination. Billing teams must ensure providers rendering services are in-network or have prior approval, with limited exceptions for emergency services, unavailable in-network providers, and certain hospital types.
Action Required
By June 30, 2026: (1) Billing team must implement verification process to confirm all care providers rendering services in facility-based settings are Anthem-participating providers before claim submission. (2) Update billing software or claim submission procedures to flag claims involving nonparticipating providers for review. (3) Providers and facility administrative staff must coordinate to ensure in-network provider availability; if nonparticipating provider is necessary, obtain prior written approval from Anthem before service delivery. (4) Train front desk and scheduling staff to direct members to in-network providers when scheduling facility-based care. (5) Review exceptions (emergency services, prior approval cases, geographic unavailability, rural/critical access/safety-net hospitals) and create documentation protocols for exception claims. Failure to comply will result in 7.5% penalty reduction on affected facility claims, potential network termination, and member balance billing liability.