CurrentAnthemPolicy N/A

Anthem Medicare-based rates for CAH claims

This policy describes Anthem Blue Cross and Blue Shield's use of CMS Medicare cost-report–derived rates to process claims from Critical Access Hospitals (CAHs) for individual Medicare Advantage and MMP members, and the limited situations where a MAC rate letter or additional information is still required.

Policy Summary

PayerAnthem

PolicyAnthem Medicare-based rates for CAH claims

Policy CodePolicy N/A

Change TypeProcess change (rate source adoption)

Effective DateAug 7, 2017

Next Review DateN/A

Key ActionNon-contracted CAHs generally do not need to submit a MAC rate letter for individual Medicare Advantage and MMP member claims; submit a MAC rate letter in the specified exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Usually not requiredMAC letter usually not required

Three exceptionsExceptions listed

08/07/2017Effective date

CAH Claim Processing Rules

CAH claim processing and documentation requirements

Anthem processes CAH claims using its Medicare-based rate database but requires MAC rate letters or updates in limited circumstances.

Anthem will generally process claims from non-contracted CAHs for individual Medicare Advantage and MMP members using its Medicare cost-report–derived rate database without requiring a Medicare Administrative Contractor (MAC) rate letter.

Contracted CAHs that are compensated using Medicare rates must continue to submit MAC rate letters to their Anthem network managers as required by their contract.

Non-contracted CAHs must submit a MAC rate letter for claims for Medicare Advantage group-sponsored members.

All CAHs must notify Anthem of a change in Method (I/II). Note: Method II reimbursement applies to contracted CAHs only if specified in the contract.

Rate Source and Use

Policy Summary

PayerAnthem

PolicyAnthem Medicare-based rates for CAH claims

Policy CodePolicy N/A

Change TypeProcess change (rate source adoption)

Effective DateAug 7, 2017

Next Review DateN/A

Key ActionNon-contracted CAHs generally do not need to submit a MAC rate letter for individual Medicare Advantage and MMP member claims; submit a MAC rate letter in the specified exceptions.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

When Additional Documentation or MAC Rate Letter Is Required

Documentation Required

When MAC Rate Letter Is Required

Anthem generally will not require a Medicare Administrative Contractor (MAC) rate letter to process claims from non‑contracted Critical Access Hospitals (CAHs) for individual Medicare Advantage and MMP members because Anthem uses a CMS‑sourced Medicare rate database. However, a MAC rate letter or additional information is required in these situations:

Contracted CAHs that are compensated using Medicare rates must continue to submit MAC rate letters to their Anthem network manager as required by their contract.
Non‑contracted CAHs must submit a MAC rate letter for claims for Medicare Advantage group‑sponsored members.
All CAHs must notify Anthem and submit updated documentation when their CAH Method status changes (for example, from Method II to Method I or vice versa). Note: Method II reimbursement applies to contracted CAHs only if specified in the contract.

Key Terms

MAC rate letter — definition & when required

DefinitionMAC rate letter: a rate determination or documentation from the Medicare Administrative Contractor that Anthem may require to process CAH claims in specified situations

When Anthem usually does not require itAnthem usually will not need a MAC rate letter to process claims from non‑contracted CAHs for individual Medicare Advantage and MMP members

Required situations(1) Contracted CAHs compensated using Medicare rates must continue to submit MAC rate letters to their Anthem network managers as required by contract; (2) Non‑contracted CAHs must submit a MAC rate letter for claims for Medicare Advantage group‑sponsored members

Method I/II — Method II reimbursement notes

DefinitionMethod II reimbursement: a CAH reimbursement method; Method II reimbursement applies to contracted CAHs only if specified in contract

Notification requirementAll CAHs should update Anthem regarding a change in status in Method (change between Method I and II)

Contract implicationContracted CAHs subject to Method II must have that method specified in their contract; otherwise it does not apply