Effective October 15, 2018, Medicaid claims received by Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) containing procedure codes not priced by the fee schedule listed in your Provider Agreement may be denied or pended for further review.


To avoid claim denials, please ensure you’re billing with the most current, applicable procedure code.


Why is this change necessary?


We have paid certain claims at 15 or 30 percent of billed charges, which is outlined as Market Terminal Pricing and/or Contracted Terminal Pricing on the Explanation of Payment. This occurs when a claim is submitted with a CPT or HCPCS code (with or without modifier) that is not priced or not listed on the fee schedule on which your Provider Agreement is based. This includes a specific revenue code billed with and/or without a service code that is not covered under NV Medicaid.


We identified that paying a percentage of charges for these services may not be accurate. In many cases, the service is:

  • Not a covered benefit.
  • Billed with an invalid procedure code (or procedure/modifier combination).
  • An unlisted code that should be priced manually.
  • A code not separately reimbursed.
  • A different code used by state Medicaid with a fee allowance for the service and/or item.


What is the impact of this change?


To ensure accurate processing of claims going forward, any procedure code billed that is not listed on the applicable fee schedule(s) will be denied or pended for further information.


You may receive a claim denial if you do not bill with the most current, applicable procedure codes to reflect the services rendered, per your Provider Agreement and fee schedules. Claims billed in line with the fee schedule will be processed accordingly.


What if I need assistance?


If you have questions about this communication, received this fax in error or need help with any other item, contact your local Provider Relations representative or call Provider Services at 1‑844-396-2330.


ANV-NU-0012-18 September 2018

Featured In:
November 2018 Anthem Provider Newsletter - NV