Anthem BCBS Connecticut Reimbursement Policies Updates

September 2018 ~

Anthem Blue Cross and Blue Shield (BCBS) Connecticut (CT) has updated several of its reimbursement policies, including OBGYN policies, and language changes within its policies for professional reimbursement.

Durable Medical Equipment Professional Reimbursement Policy Reminders

In the April 2016 edition of Network Update, Anthem shared details about the professional reimbursement policy, Durable Medical Equipment. Following are some important reminders about this policy.

  • Certain DME is not routinely purchased up-front; rent-to-purchase durable medical equipment (DME) is eligible for rental reimbursement up to the purchase price or 10 months rental, whichever comes first. Anthem is receiving claims billed with up-front purchases and is denying those claims because they must be billed as rent-to-purchase. If a provider receives such a denial, Anthem asks that providers do not request a medical necessity review as that was not the reason for the denial. Instead, please bill claims for these services correctly as rent-to-purchase.
  • For dates of service on or after July 1, 2016, the following HCPCS codes for sleep apnea equipment are only eligible for reimbursement when reported as rented items, and should not be reported with DME purchase modifiers NR (new when rented (use modifier NR when DME that was new at the time of rental is subsequently purchased)), NU (new equipment), or UE (used durable medical equipment):
    • ž E0470 (respiratory assist device, bi-level pressure capability, without backup rate feature)
    • ž E0471 (respiratory assist device, bi-level pressure capability, with back-up rate feature)
    • ž E0561 (humidifier, non-heated, used with positive airway pressure device)
    • ž E0562 (humidifier, heated, used with positive airway pressure device)
    • ž E0601 (continuous positive airway pressure (CPAP) device)

For more information about the Durable Medical Equipment reimbursement policy, visit the professional reimbursement policy webpage at

Diagnosis-Related Group Newborn Inpatient Stays Facility Reimbursement Policy Update

Effective for dates of service on and after September 1, 2018, Anthem will implement the new facility reimbursement policy, Diagnosis-Related Group (DRG) Newborn Inpatient Stays.

The following details provide important information about this policy:

  • All newborn inpatient stays must include sufficient documentation or prior authorization to support an admission to a level of care area beyond the newborn nursery, such as the neonatal intensive care unit (NICU), or for the higher level of care associated with more complex newborn DRG.
  • Newborn claims submitted for a higher level of care DRG that do not include the appropriate documentation, or those submitted with only newborn care revenue codes (170 and 171) and no prior authorization will be automatically processed based on the normal newborn rate.
  • Current prior authorization guidelines for normal newborn and higher level of care newborn inpatient stays apply.

Anthem BCBS has created a new remark code to help provide additional detail in the above mentioned claim scenarios. The explanation, “Claim did not meet criteria for higher DRG payment. Level of care adjustment has been made. Claim paid at Normal Newborn DRG.” will appear on the provider remit when a claim is submitted with a higher level of care newborn DRG code and the required documentation or prior authorization is not on file. Providers may appeal decisions related to the DRG Newborn Inpatient Stays policy by following their normal appeal process and submitting the appropriate supporting clinical documentation.

For more information about DRG Newborn Inpatient Stays reimbursement policy, visit the facility reimbursement policy webpage at

Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing (CG-MED-43) Not Implemented

In the October 2017 edition of the Network Update, Anthem announced a new coverage guideline, Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing (CG-MED-53) to be effective January 1, 2018. Please be advised that CG-MED-53 was not implemented.

Review of Reimbursement Policies – Professional

The following professional reimbursement policies were reviewed and may have minor language changes; however, the changes do not cause significant changes to the policies’ position or criteria:

  • Documentation Reporting Guidelines for Consultations
  • Duplicate Reporting of Diagnostic Services
  • Frequency Editing
  • Overhead Expense for Office Based Surgery and Diagnostic Testing
  • Sleep Studies and Related Bundled Services & Supplies
  • Unit Frequency Maximums for Drugs and Biologic Substances

Update to Use of a Non-Participating Provider Advance Patient Notice Policy

Participating providers and facilities are asked to review the updated Use of a Non-participating Provider Advance Patient Notice Policy. Effective as of June 1, 2018, Anthem has updated the policy to clarify its scope and purpose.



Source(s): Anthem Blue Cross and Blue Shield Network Update Connecticut June 2018;