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Anthem to begin pre-payment modifier audit process

August 15, 2019


Anthem Blue Cross recently notified physicians that it will begin conducting pre-payment reviews for claims with certain modifiers for dates of service on or after October 1, 2019. According to the June 27, 2019, notice, the pre-payment modifier review will focus on claims billed with modifiers 25, 59, 57, LT/RT and other anatomical modifiers to determine whether it is appropriate for the modifier to bypass the edit.

According to the notice, registered nurses and coders will review claims that are pended to determine whether the utilization of the modifier is appropriate. Anthem has advised the California Medical Association (CMA) that the review may also include a review of past claims and provider specialty to make a determination on whether it believes use of the modifier was appropriate. Based on that review, the claim will either be paid or denied. There will be no request for medical records prior to a claim determination being made.

Physicians who wish to dispute a denial will need to submit a written appeal along with medical records through the Anthem Provider Dispute Resolution process.

CMA has expressed concerns that the new policy will have a negative impact on physicians using the modifiers correctly, as it will require them to submit a written appeal with medical records in order to possibly be paid.

The new Anthem modifier validation process comes on the heels of the recent implementation of Anthem Blue Cross’ policy denying certain evaluation and management (E/M) services submitted with modifier 25. The Anthem modifier 25 policy will deny an E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record for the same provider (or a provider with the same specialty within the same group TIN).

CMA remains very concerned with the adverse impacts of these new policies upon physicians. We have engaged with AMA and other state medical societies to escalate this issue so we can continue the dialogue with Anthem regarding these concerns. 

Providers with questions regarding the pre-payment modifier review or modifier 25 policy should contact Anthem at CaContractSupport@anthem.com.

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