Important Colorado Reimbursement Updates & Changes

Jan 15, 2020 | Uncategorized

Anthem and Cigna have released updates regarding the reimbursement updates and changes. These changes will go into effect in March 2020. For more information on the updates and the changes that may affect you, read below!nnAnthem sent out a Notice of Material Change (NOMC), dated December 1st, 2019. This is notice of Anthem changing the reimbursement for Advanced Practitioners (NPs and PAs), effective March 1st, 2020. Moving forward, Anthem will no longer reimburse based on the “incident to” rules and Advanced Practitioners will be reimbursed at 85% of the contracted rate. This comes as a 15% decrease in reimbursement for Advanced Practitioners. This also means that any Advanced Practitioners that have not been added to Anthem’s system will need to submit new provider applications.nnAll provider files must be finalized by 03/01/20 for providers to be reimbursed. If submitting 10+ providers, Anthem has offered a roster format to expedite the process. If submitting less than 10 providers, each file will need to be submitted via Availity for processing. Anthem has assured Welter Healthcare Partners that provider files will move quickly when submitting via a roster and there should be no concern for the effective date. If there are fewer than 10 providers to be submitted, then individual new provider applications need to be submitted through Availity as soon as possible. Advanced Practitioners do not require full credentialing unless an NP would like to be listed as a PCP, so these files should be processed more quickly; however, we are within the 90-day timeframe.nnTo summarize, Anthem is essentially making three distinct and important changes that will affect your practice:n


  1. Anthem will no longer recognize and reimburse based on the “Incident to” rule. This includes all services rendered by any eligible provider, even if the services meet Medicare guidelines.
  2. n

  3. Anthem is requiring all Advanced Practitioners (NPs and PAs) to be processed in their system, effective March 1st, 2020. Per Anthem, all Advanced Practitioners are eligible to submit claims directly to Anthem so new applications must be submitted if they are not loaded in the system.
  4. n

  5. All services rendered by Advanced Practitioners will be reimbursed at 85% of the applicable contract rate. This will come at a 15% decrease to your current contracted rate.
  6. n

nIf you need help or have additional questions regarding these reimbursement changes, please don’t hesitate to contact us!n