ExchangeDocumentationMedium impact
[New York] EMR alerts aim to close gaps in care for Affordable Care Act members
Anthem BCBS·NY·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Anthem is implementing EMR alerts to identify care gaps for ACA plan members, requiring providers to review notifications, schedule follow-up visits, and submit claims with complete clinical documentation and specific coding to support risk adjustment reporting compliance.
Action Required
By May 1, 2026: Providers and billing staff must implement workflow to monitor EMR alerts for care gap notifications. Clinical teams should review alerts, schedule patient follow-ups, and ensure comprehensive clinical documentation is completed. Billing team must verify that all claims submitted for ACA members include highest specificity coding and complete clinical data to support risk adjustment. Contact Anthem Commercial Risk Adjustment team at prospectiveteam@anthem.com with implementation questions. Failure to address flagged care gaps and submit complete clinical documentation may result in compliance issues with ACA program reporting requirements.