Medicare AdvantageReimbursementHigh impact
[California] Reimbursement policy update: Preventive Medicine and Sick Visits on the Same Day
Anthem BCBS·CA·Claims & Billing
Effective date
Apr 1, 2026
We identified it
May 3, 2026
Summary
Effective April 1, 2026, Anthem Medicare Advantage in California will reimburse sick visits at 50% when billed on the same day as preventive/wellness visits (which receive 100% reimbursement), and preventive services at 50% when billed the same day as wellness visits (which receive 100% reimbursement). Billing teams must adjust claim processing and provider education to account for these reduced reimbursement rates for same-day bundled visits.
Action Required
Before April 1, 2026: (1) Billing team must update claim adjudication rules in billing software to automatically apply 50% reimbursement for sick visits when submitted on the same date of service as preventive or wellness visits, and 50% for preventive services when submitted the same day as wellness visits. (2) Providers and front desk staff must be educated on the new bundling rules to set appropriate patient expectations for cost-sharing and out-of-pocket costs on same-day visits. (3) Update encounter forms and EMR templates to flag when both sick and preventive/wellness services are being billed on the same date to ensure correct coding and reimbursement application. (4) Review and revise any standing orders or protocols that routinely combine sick and preventive visits on the same appointment. Failure to implement these changes will result in claim denials or incorrect reimbursement amounts for affected claims.