Anthem Blue Cross recently began enforcing a maternity claims policy that is creating significant administrative and financial burdens for physicians. The policy outlined in the Anthem California Facility and Professional Provider Manual, requires physicians to report the gestational age at delivery on all professional maternity claims by including the appropriate ICD-10 Z3A diagnosis code. Many practices—unaware of the requirement—are now receiving repayment demands on previously paid claims, triggering time-intensive dispute resolution, re-billing and payment reconciliation work.

This requirement applies to the following CPT^® delivery procedure codes: 59400, 59409, 59410, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, and 59622.

While Anthem updated its provider manual in January 2020 to include this requirement, the California Medical Association (CMA) has raised concerns that the change was not clearly communicated to physicians. If the policy had been properly enforced, impacted claims should have been denied upon submission rather than paid and later subject to recoupment. Instead, Anthem just recently began enforcing the policy, applying it retroactively, and forcing practices to absorb the administrative burden of appeals, corrected claim submissions and repayment demands. The lack of timely notice and clear guidance on how to address these recoupments has left many practices scrambling to resolve claim issues and ensure proper payment.

CMA is seeking clarification from Anthem on the five-year lapse in policy enforcement, the lack of clear notice to physicians and the steps practices should take to submit corrected claims to ensure proper reimbursement.

How to Respond to Overpayment Notices

Given the potential financial and operational impact of overpayment recovery efforts, it is essential for affected physicians to respond promptly and appropriately to overpayment notices. Under California law, physicians who disagree with an overpayment request must initiate a dispute within 30 working days from receipt of the notice. Failure to do so may result in Anthem withholding funds from future payments.

Fully insured health plans may request refunds within 365 days from the date of payment, except in cases of fraud or misrepresentation. When attempting to recoup, health plans are required to issue a written request that clearly identifies the claim in question, including the patient’s name, date of service, and a detailed explanation of the reason for the overpayment. Physicians then have 30 working days to dispute this request.

For providers dealing with ERISA self-insured plans, contracted providers have up to four years to pursue refunds, while non-contracted providers have two years.

If a health plan attempts to recover funds outside of these timeframes, or if the plan fails to provide the necessary notice and opportunity for dispute, physicians are encouraged to challenge the request in writing.

CMA Is Here to Help

CMA’s reimbursement experts are available to support practices as they navigate the challenges posed by Anthem’s enforcement of this policy. Members can contact the CMA Center for Economic Services at economicservices@cmadocs.org or (800) 786-4262.

Additionally, physicians may find valuable information on their rights and options for handling health plan refund requests in CMA health law library document #7512, “Plan Requests for Refunds from Physicians.” This document is available free of charge to CMA members, and nonmembers may purchase it for $3 per page.