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Reimbursement Policies

These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by Anthem Blue Cross and Blue Shield if the service is covered by a BadgerCare and Medicaid SSI program member’s Anthem Medicaid benefit plan. The determination that a service, procedure, item, etc. is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s state of residence. ...Read More

You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claims submissions. Services should be billed with Current Procedural Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) must be fully supported in the medical record or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities.

If appropriate coding/billing guidelines or current reimbursement policies are not followed, we may:

  • Reject or deny the claim
  • Recover or recoup the claim payment

Anthem Blue Cross and Blue Shield reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or Centers for Medicare & Medicaid Services contracts or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, we strive to minimize these variations.

Anthem Blue Cross and Blue Shield reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site.

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 Reimbursement Administration - General
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