CurrentAnthemPolicy G-05006

Reimbursement Policy Consultations

Defines Anthem New York Medicaid reimbursement policy for face-to-face medical consultations by physicians and qualified nonphysician practitioners, including documentation, pre/postoperative considerations, and nonreimbursable situations; applies to providers billing under NY Medicaid.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Consultations

Policy CodePolicy G-05006

Change TypeNo material change

Effective DateDec 2, 2025

Next Review DateN/A

Key ActionRequest consultations by the attending provider and include a written report meeting documentation requirements to qualify for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

face-to-faceconsultation modality reimbursed

written reportrequired documentation

25/57modifier requirement

telephonenonreimbursable

NY Medicaidapplicability

Reimbursable Consultation Criteria

Reimbursable consultation criteria

Consultations are reimbursable when ALL of the following documentation and process requirements are met:

ALL of the following

Requested by the attending provider or appropriate source (written or verbal).
Provided within the scope and practice of the consulting provider.
Includes a personal examination of the patient.
Consulting provider completes a written report that includes member history (including chief diagnosis and/or complaint), examination, physical findings, recommendations for future management and/or ordered services, the attending provider's request for the consultation, the reason for the consultation, and documentation that the consulting provider communicated the findings to the attending provider and the member's authorized representative.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Consultations

Policy CodePolicy G-05006

Change TypeNo material change

Effective DateDec 2, 2025

Next Review DateN/A

Key ActionRequest consultations by the attending provider and include a written report meeting documentation requirements to qualify for reimbursement.

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.

Procedure Codes and Modifier Guidance

Consultation codesCPT | HCPCS | mixed

Appropriate consultation code per state Medicaid or CPT guidelines; standard correct coding applies.

Modifier requirement for same‑day procedures

Modifier requirementIf the consulting provider performs a definitive therapeutic surgical procedure on the same day as the consultation for the same member, the consultation must be reported with modifier 25 or modifier 57, whichever is most appropriate.

Consequence if not reportedIf the appropriate modifier is not reported, the consultation is considered included in the reimbursement for the therapeutic surgical procedure and is not separately reimbursable.

ApplicabilityApplies when the definitive therapeutic surgical procedure is performed the same day as the consultation for the same member.

Modifier selection guidanceUse whichever modifier (25 or 57) is most appropriate for the service rendered in accordance with coding guidance.

Request, Documentation, and Payment Basis

Billing Rule

Who may request consultation and how payment is determined

Consultation must be requested by the attending provider or other appropriate source; reimbursement is determined by the fee schedule or the contracted/negotiated rate using the appropriate consultation code per state Medicaid or CPT guidelines.

Request may be written or verbal; must originate from the attending provider or appropriate source.
Payment is based on the fee schedule or contracted/negotiated rate using the appropriate consultation code per state Medicaid or CPT guidelines.

Key Definitions

Consultation — definition

DefinitionConsultation: The opinion or advice of a specialist requested by another physician or other appropriate source regarding evaluation and/or management of a specific problem.

Request sourceMust be requested by another physician or other appropriate source (written or verbal request documented).

Documentation requirementConsulting provider must complete a written report including member history, exam, findings, recommendations, reason for consult, and documentation of communication to the attending provider.

Service typeFace-to-face medical consultation with personal examination of the patient (telephone consultations are not reimbursable).

Second opinion — definition

DefinitionSecond Opinion: An opinion obtained from an additional healthcare professional prior to the performance of a medical service or a surgical procedure.

PurposeMay be part of a formalized process (voluntary or mandatory) to educate a patient about treatment alternatives or to determine medical necessity.

TimingObtained prior to performance of the contemplated medical service or surgical procedure.