Medicare AdvantageCoverageHigh impact
[California] New reimbursement policy: Critical Care to Home — Facility
Anthem BCBS·CA · Emergency Medicine, Critical Care·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, 99292 with revenue code 045X) when a member is treated in the emergency room and discharged home. Billing teams must identify and deny these claims, and providers are prohibited from balance billing members for these non-reimbursable services.
Action Required
By March 15, 2026: Billing team must update claim scrubbing software to deny CPT 99291 and/or 99292 billed with revenue code 045X when member disposition is 'discharged to home.' Configure system to flag these claim lines as non-reimbursable before submission to Anthem. Update billing staff training materials to explain this policy change. Add documentation to provider encounter forms reminding emergency medicine providers that Critical Care codes for ED-to-home patients will not be reimbursed. Communicate policy to all providers and front desk staff. Failure to implement this change will result in claim denials post-April 1, 2026, and potential audits for balance billing violations.