Provider Preventable Conditions (PPC) reimbursement
Defines Anthem Medicare Advantage reimbursement stance for provider preventable conditions (HCACs and OPPCs) and reporting requirements for inpatient claims; applies to Anthem Medicare Advantage providers in the listed Medicare Advantage states.
No material clinical or coverage changes in this revision.
Reimbursement and Coverage Criteria for Provider Preventable Conditions
Reimbursement criteria for PPCs
Anthem Medicare Advantage does not reimburse for Provider Preventable Conditions (PPCs) except when provider, state, federal, or CMS contracts or requirements indicate otherwise. The rules below describe reimbursement and submission requirements for Health Care-Acquired Conditions (HCAC) and Other Provider Preventable Conditions (OPPC).
HCAC — inpatient POA and DRG impact
- Present on Admission (POA) indicator is required for all inpatient primary and secondary diagnoses; failure to include the POA indicator may result in claim denial or rejection.
- If the POA indicator identifies a HCAC, charges and/or days related to the HCAC will be removed from the claim when calculating DRG reimbursement for inpatient hospital services.
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.