CommercialReimbursementHigh impact
[New York] Outpatient facility claims update: modifier 26 (professional services) on UB‑04
Anthem BCBS·NY·Provider Bulletin
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem will no longer provide separate facility reimbursement for outpatient facility claims that include modifier 26 (professional services). This aligns with Anthem's Facility Guidelines for Claims Related to Professional Services policy. Billing teams must stop expecting dual reimbursement (facility + professional) for lines billed with modifier 26 on UB-04 claims.
Action Required
By March 31, 2026: Billing team must review all outpatient facility claims currently using modifier 26 to identify affected claims. Update billing system logic to prevent submission of UB-04 claims with modifier 26 expecting separate facility reimbursement. Providers must document which services will no longer receive dual reimbursement and adjust charge capture accordingly. Educate clinical staff that modifier 26 on facility claims will not generate separate facility payment. For any claims denied under this new policy after April 1, 2026, submit through Anthem's claim dispute process with documentation of service date to request reconsideration if warranted.