CurrentAnthemPolicy G-06001

Eligible Billed Charges

Defines Anthem's rules for when billed charges are considered eligible for reimbursement under member benefit plans (California Medi‑Cal Managed Care) and describes conditions that determine reimbursement eligibility for providers.

Policy Summary

PayerAnthem

PolicyEligible Billed Charges

Policy CodePolicy G-06001

Change TypeNo material changes

Effective DateNov 4, 2024

Next Review Date

Key ActionVerify authorization requirements as one of the conditions determining reimbursement eligibility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11/04/2024last approval/effective date

9conditions that determine reimbursement

5terms defaulting to eligible charges

all providersprovider applicability

Eligibility and Exclusions

Eligibility and exclusions

Anthem allows reimbursement of eligible charges only when the following conditions are met and exclusions do not apply.

ALL of the following

Member program eligibility
Member must be enrolled in the appropriate program for coverage.
Provider program eligibility
Provider must be eligible in the relevant program.
Benefit coverage
Service must be covered under the member's benefit plan.
Authorization requirements

Policy Summary

PayerAnthem

PolicyEligible Billed Charges

Policy CodePolicy G-06001

Change TypeNo material changes

Effective DateNov 4, 2024

Next Review Date

Key ActionVerify authorization requirements as one of the conditions determining reimbursement eligibility.

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.

Coding and Documentation

Accepted coding systemsmixed

CPT, HCPCS, revenue codes

Use industry-standard CPT, HCPCS, and revenue codes; billing must be supported in the medical record.

Documentation support — requirement that billed codes be supported in the medical record/office notes

RequirementAll billed CPT, HCPCS, and/or revenue codes must be fully supported in the medical record and/or office notes.

ScopeApplies to participating and non‑participating professional providers and facilities unless otherwise noted.

Consequence of noncomplianceIf coding/billing guidelines or current reimbursement policies are not followed, Anthem may reject or deny the claim and/or recover/recoup claim payment.

PurposeSupports accurate claims submissions and establishes the basis for reimbursement when services are covered under a member's benefit plan.

Provider Responsibilities

Prior Authorization

Confirm required prior authorization for services

Verify any required prior authorization is obtained before rendering services, as Authorization requirements are a condition for reimbursement eligibility. Failure to obtain required authorization may result in claim denial, recovery, or recoupment of payment.

Authorization requirements are listed as a specific condition determining eligibility for reimbursement.
If appropriate coding/billing guidelines or current reimbursement policies are not followed, Anthem may reject or deny the claim and recover and/or recoup claim payment.

Documentation Required

Document medical necessity and verify member state residency

Ensure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and are consistent with the member's state of residence; services not meeting these requirements may be denied. Use proper CPT/HCPCS/revenue codes and document services fully in the medical record/office notes to support medical necessity.

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and to the member's state of residence.
Services should be billed with CPT, HCPCS, and/or revenue codes that are fully supported in the medical record and/or office notes.
If coding/billing guidelines or reimbursement policies are not followed, Anthem may reject or deny the claim and recover and/or recoup claim payment.

Key Definitions

Eligible Charges — definition of charges subject to reimbursement conditions

DefinitionCharges billed by the provider that are subject to conditions and requirements that make the service eligible for reimbursement.

Conditions that determine eligibilityMember/program eligibility, provider program eligibility, benefit coverage, authorization requirements, provider manual guidelines, administrative/clinical policies, reimbursement/code‑editing logic.

ExclusionsItems provided to the member free of charge will not be reimbursed.

Default termsIn absence of contract language, terms such as 'billed charges', 'covered charges', 'allowed charges', 'percent of charge' default to eligible charges.