Anthem Blue Cross and Blue Shield reimbursement policies

Anthem Blue Cross and Blue Shield (Anthem) reimbursement policies for Ohio Medicaid became effective February 1, 2023 and are located on the Anthem provider website.

For dates of service (DOS) that span prior to February 1, 2023, the legacy Paramount Medicaid policies will apply for members who are transitioning to Anthem for their Medicaid coverage. For any claim whose DOS starts prior to and ends after February 1, 2023, providers will continue to use Paramount Medicaid policies. The legacy Paramount reimbursement policies can be found at https://www.paramounthealthcare.com/services/providers/reimbursement-policies.

Anthem reimbursement policies apply to providers who serve members enrolled in Anthem with dates of service on or after February 1, 2023, and are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal, or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, Anthem strives to minimize these variations. To view the Anthem reimbursement policies for Ohio Medicaid, visit the provider self‑service website at https://providers.anthem.com/oh.

What does this mean to me?

Refer to the reimbursement policy websites, your respective provider manual, and/or your respective provider contract as a guide for reimbursement criteria. Reimbursement policies serve as a guide to assist you in accurate claim submissions and to outline the basis for reimbursement if the service is covered by a member’s 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. Proper billing and submission guidelines are required along with the use of industry-standard, compliant codes on all claim submissions.  

Reimbursement policies undergo reviews for updates to state contracts, rules, and requirements, as well as federal and CMS requirements. Additionally, updates may be made at any time if we are notified of a mandated change or due to an Anthem business decision. We reserve the right to review and revise our policies when necessary. When there is an update, we will publish the most current policy at https://providers.anthem.com/oh.

Code and clinical editing

Anthem applies code and clinical editing guidelines to evaluate claims for accuracy and adherence to accepted national industry standards and plan benefits. We use sophisticated software products to ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices. Editing sources include but are not limited to CMS National Correct Coding Initiative, Medical Policies, and Clinical Utilization Management Guidelines. Anthem is committed to working with you to ensure timely processing and payment of claims.

What if I need assistance?

The complete set of policies are available at https://providers.anthem.com/oh. If you have questions, visit the provider self-service website. You may also contact your Anthem Provider Experience consultant.

If you have legacy Paramount reimbursement policy questions related to claims prior to and/or spanning past February 1, 2023, contact a Paramount Provider Services representative or call 419-887-2535 or 800‑891‑2542.

Reimbursement policies

Refer to the complete list of reimbursement policies on the reimbursement policy website, your provider manual, and/or your provider contract. These policies apply unless provider, federal, or CMS contracts and/or requirements indicate otherwise.