CurrentAnthemPolicy G-06111

Medical Recalls, Reimbursement Policy

Governance of reimbursement for repair, replacement, and procedures related to medically recalled items for AMH Health Medicare Advantage members; affects providers submitting claims to AMH Health.

Policy Summary

PayerAnthem

PolicyMedical Recalls, Reimbursement Policy

Policy CodePolicy G-06111

Change TypeAdded implantable deviceseditorial and administrative updates

Effective Date05/22/2024

Next Review DateN/A

Key ActionProviders should bill the appropriate condition code, value code, modifier, and/or diagnosis code to identify a medically recalled item.

SourceLink

POLICY UPDATE CHANGES

Added implantable devices under applicable items.

Added the words 'or item' to policy language.

Updated References and Research Materials and added Modifier Usage to the related coding section (2022 review).

6listed applicable item categories

05/22/2024last approval/effective date

G-06111identifier

Reimbursement Criteria for Recalled Items

Reimbursement criteria for recalled items

AMH Health reimbursement stance for recalled items and related procedures.

AMH Health does not allow reimbursement for repair or replacement of items due to a medical recall unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

The following item categories are included as applicable items: durable medical equipment; supplies; prosthetics; orthotics; drugs/vaccines; implantable devices.

AMH Health will allow reimbursement of medically necessary procedures to remove and replace recalled or replaced devices or items.

Payment reduction: AMH Health will not be responsible for the full cost of a replaced device or item if an inpatient or outpatient facility receives partial or full credit for the device or item. Payment will be reduced by the amount of the device or item credit.

Policy Summary

PayerAnthem

PolicyMedical Recalls, Reimbursement Policy

Policy CodePolicy G-06111

Change TypeAdded implantable deviceseditorial and administrative updates

Effective Date05/22/2024

Next Review DateN/A

Key ActionProviders should bill the appropriate condition code, value code, modifier, and/or diagnosis code to identify a medically recalled item.

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.

Billing, Reimbursement, and Legal Participation

Billing Rule

Billing and reimbursement actions for recalled items — Providers should bill appropriate condition code, value code, modifier, and/or diagnosis code to identify a medically recalled item.

When applicable, providers should bill the appropriate condition code, value code, modifier, and/or diagnosis code to identify a medically recalled item. Bill using existing coding guidance to indicate the item or device was medically recalled and include any required billing indicators for repair, replacement, or return processing so claims accurately reflect the recall-related service.

Providers must include the appropriate condition code, value code, modifier, and/or diagnosis code on claims to identify a medically recalled item.
Include documentation on the claim or in the medical record supporting that the item was recalled and the reason for repair or replacement.
Use modifiers and diagnosis codes per standard coding guidelines to indicate recall-related services (e.g., replacement of an implanted device) and to distinguish recall work from routine care.

Note

Recoupment and legal participation — AMH Health will participate and provide documentation for class action lawsuits related to medical recalls and may recoup or recover fees.

AMH Health will: - Participate and provide any applicable documentation required in any applicable class action lawsuits due to a medical recall. - Supply providers with medical recall information for dissemination to applicable members. If AMH Health has reimbursed the provider for repair or replacement of items, or procedures related to items due to a medical recall, AMH Health is entitled to recoup or recover fees from the manufacturer and/or distributor, as applicable. If AMH Health reimbursed the provider the full or partial cost of a replaced device or item and the provider received full or partial credit for the device or item, AMH Health is entitled to recoup or recover fees from the provider.

AMH Health may recoup or recover fees from manufacturers or distributors when it has reimbursed providers for recall-related repair or replacement.
AMH Health may recoup or recover fees from providers when AMH Health has reimbursed costs and the provider later receives full or partial credit for the device or item.
AMH Health will provide documentation and participate in class action lawsuits related to medical recalls, and will supply providers with recall information for member outreach.

OpenPayer

Medical Recalls, Reimbursement Policy

Reimbursement Criteria for Recalled Items

Recalled Item Identification Codes

Billing, Reimbursement, and Legal Participation

Policy Definitions