Medicare AdvantageDocumentationHigh impact
[California] Enhancing claims accuracy for inpatient sepsis and some newborn DRG submissions with full medical records
Anthem BCBS·CA · Critical Care, Pediatrics, Infectious Disease·Coding
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem requires full medical records to be submitted with inpatient sepsis and certain newborn DRG claims (Medicare Advantage and Commercial) at the time of initial claim filing to validate correct DRG assignment. Claims submitted without complete medical records may be denied until records are provided. Normal newborn MS-DRG 795 and APR-DRG 640-1 are excluded from this requirement.
Action Required
By July 1, 2026: (1) Billing team must implement process requiring complete medical records submission with all inpatient sepsis and qualifying newborn DRG claims at initial filing. (2) Update billing system and claim submission workflows to flag sepsis and newborn claims for mandatory medical record attachment before submission. (3) Register facility for Availity Essentials and Medical Attachments application if not already registered at https://Availity.com to enable digital record submission and receive documentation notifications. (4) For Epic EMR users, contact emrintegration@carelon.com to configure automatic electronic medical record sharing. (5) Train clinical and billing staff on new documentation requirements and digital submission options via Anthem's Learning Hub. (6) Establish process to proactively attach medical records digitally with initial claim using Availity Essentials or Epic integration. Consequences: Claims submitted without complete medical records will not be eligible for reimbursement until records are provided, causing payment delays and potential claim denials.