CommercialCoverageHigh impact
[New York] New reimbursement policy: Critical Care to Home — Facility
Anthem BCBS·CT, GA, IN, KY, MO, NV, NH, NY, OH, WI · Critical Care, Emergency Medicine·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem will no longer reimburse Critical Care services (CPT 99291 with revenue code 045X) when a member is treated in the emergency room and discharged home. Critical Care services remain reimbursable only if the member requires inpatient admission, trauma, or observation services. Providers may not balance bill members for these non-reimbursable claims.
Action Required
By March 31, 2026: Billing team must update claim adjudication logic in billing software to deny CPT 99291 claims with revenue code 045X when the discharge disposition is 'home' for Anthem Commercial plans in applicable states. Implement automated edits to flag or reject these claim lines before submission. Providers must be notified via bulletin to ensure they do not submit these claims or balance bill members. Train billing staff on the new policy to distinguish reimbursable Critical Care (inpatient, trauma, observation) from non-reimbursable ED-to-home Critical Care. Verify encounter forms and EMR templates reflect that ED Critical Care followed by home discharge does not qualify for reimbursement.