If you work in medical billing or you’re a patient trying to make sense of your insurance paperwork you’ll run into Anthem Blue Cross sooner or later. As one of the largest health insurers in the U.S., Anthem covers millions of members, and that means it also processes millions of claims every year.
The upside? Wide coverage and strong provider networks. The downside? Anthem has its own set of rules for authorizations, claim submissions, and appeals and missing a single step can cost time, money, or both.
Let’s break it down, from the first eligibility check to the final payment.
1. Anthem Blue Cross at a Glance
Anthem Blue Cross is part of the Blue Cross Blue Shield Association (BCBSA)—a network of 34 independent, locally operated companies. Anthem operates in multiple states, including California, Georgia, Indiana, Kentucky, Missouri, Nevada, New York, Ohio, Virginia, and Wisconsin, but each state may have different plan names, networks, and billing rules.
Key things to know:
- Not all Anthem plans are identical. Two patients with “Anthem Blue Cross” on their cards may have completely different benefits.
- State regulations matter. Anthem policies often reflect state-specific insurance laws and mandates.
- Employer vs. individual coverage affects claim processing speed, allowable charges, and appeal rights.
2. Why Anthem Blue Cross is a Big Deal in Medical Billing
Anthem is consistently ranked among the top three largest health insurance providers in the U.S. For billers, this means:
- High claim volume—you’ll encounter Anthem almost daily.
- Frequent updates to authorization and coding policies—miss an update and your denial rates go up.
- Varied product lines—Medicare Advantage, Medicaid managed care, commercial group, individual, dental, vision, and prescription drug plans.
3. Anthem’s Medical Billing Workflow (Step-by-Step)
Here’s how most billers interact with Anthem, from patient scheduling to final claim adjudication:
Step 1: Eligibility Verification
- Use Availity Essentials (Anthem’s preferred clearinghouse) to verify:
- Active coverage dates
- Deductible and co-pay amounts
- In-network vs. out-of-network status
- Plan type (HMO, PPO, EPO, POS)
- Specific benefits like mental health, telehealth, chiropractic care
- Tip: Always screenshot the eligibility confirmation with the date/time—it’s proof if there’s a dispute later.
Step 2: Prior Authorization
- Anthem has strict PA rules for:
- Advanced imaging (MRI, CT, PET scans)
- Elective surgeries
- Specialty medications (especially infusion therapies)
- Outpatient rehabilitation beyond a set number of visits
- Submitting without PA can lead to automatic denial—even if the service was medically necessary.
- Where to request: Availity’s Auth/Referral tool or by phone for urgent requests.
Step 3: Medical Necessity & Documentation
- Anthem follows CMS guidelines but often has internal medical policies that outline:
- Covered ICD-10 codes
- Acceptable clinical documentation
- Missing chart notes, operative reports, or test results? Expect a delay.
Step 4: Claim Submission
- Electronic submission via Availity is fastest—most Anthem claims process in 7–14 days if clean.
- Paper claims (CMS-1500 or UB-04) can take 30+ days.
- Anthem accepts secondary claims electronically if primary EOB is attached in the correct 835/837 format.
Step 5: Claim Follow-Up
- Check claim status in Availity 5–7 days after submission.
- Anthem often flags claims for manual review if:
- The billed amount is unusually high
- Multiple modifiers are used
- There’s a mismatch between place of service and procedure code
Step 6: Payment Posting
- Payments are sent via EFT (Electronic Funds Transfer) or paper checks.
- The 835 ERA file includes payment details for automated posting in your practice management system.
Step 7: Denials & Appeals
- Anthem’s standard appeal window: 30–60 days from the denial date
- Common appeal success factors:
- Attach supporting medical records
- Reference Anthem’s own policy ID numbers
- Clearly state the reason the denial is incorrect
4. Common Anthem Denial Reasons (and How to Fix Them)
| Denial Reason | Prevention Strategy |
|---|---|
| No prior authorization | Always run PA checks for high-cost services |
| Out-of-network provider | Verify provider network status before scheduling |
| Service not covered | Confirm benefits before performing procedures |
| Incorrect coding | Use updated ICD-10 & CPT manuals |
| Missing modifiers | Apply appropriate modifiers (e.g., -25, -59) |
5. Anthem Coverage Nuances
Anthem coverage varies widely, but here are some consistent patterns:
HMO Plans
- Require PCP referrals
- Only cover in-network providers
- Lower out-of-pocket costs for patients
PPO Plans
- No referral needed
- Covers out-of-network (but at reduced rates)
- Higher premiums, more flexibility
EPO Plans
- In-network only, but no referral required
- Usually cheaper than PPO
POS Plans
- Hybrid of HMO & PPO
- Out-of-network covered with PCP referral
6. Specialty Billing Scenarios
- Dental Claims: Use CDT codes, not CPT.
- Mental Health Claims: Follow parity laws but check visit limits and required provider credentials.
- Telehealth Claims: Anthem often requires a telehealth modifier (95) and the correct POS code (02 or 10).
- Pharmacy & Specialty Drugs: May be processed through IngenioRx—requires coordination between medical and pharmacy billing teams.
7. Anthem Blue Cross vs Competitors
- Kaiser Permanente: Closed network, easier billing but fewer providers.
- UnitedHealthcare: Similar size, but Anthem’s electronic processing can be faster in certain states.
- Cigna: Often less restrictive on out-of-network coverage compared to Anthem’s HMOs.
8. Pro Tips for Billers
- Keep a state-specific Anthem policy manual—rules in California aren’t the same as Ohio.
- Log every call with Anthem’s provider service, noting date/time and representative name.
- Use Anthem’s Clinical UM Guidelines for appeal support—quoting their own policy language often turns denials around.
9. Advice for Patients
- Always confirm your plan year—deductibles reset annually.
- Use Anthem’s member portal to track claims in real time.
- Don’t ignore a denial letter—you often have multiple levels of appeal.
10. Key Takeaways
- Anthem Blue Cross is a major payer with complex but predictable rules.
- Success in billing Anthem claims comes down to verification, documentation, and follow-up.
- For patients, understanding your plan type is critical to avoiding surprise bills.