CommercialBilling CodesHigh impact
[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility policy
Anthem BCBS·NY·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem will no longer reimburse professional services billed on UB-04 forms in New York. Outpatient claims must now use modifiers PN, PO, or ER to indicate service location, with off-campus non-contracted locations receiving reduced reimbursement at 40% of allowable.
Action Required
By March 31, 2026: Billing team must implement the following changes for all Anthem Commercial claims in New York: (1) STOP billing professional services on UB-04 forms—use 1500 forms instead; (2) Update billing system rules to automatically append modifier PN for off-campus non-contracted services (reducing reimbursement to 40%), modifier PO for off-campus provider-based outpatient departments under hospital contracts, and modifier ER for off-campus emergency department services; (3) Train all billing staff on the three modifier requirements and ensure encounter forms/templates prompt providers to document service location; (4) Audit existing workflows to identify any UB-04 submissions for professional services and redirect to appropriate form/modifier combination. Providers must document the service location at point of care. Failure to use correct modifiers will result in claim denials or incorrect reimbursement; services billed on UB-04 will not be reimbursed.