Sanctioned Providers
This policy governs Anthem New York Medicaid reimbursement for providers who are excluded or debarred from state or federal healthcare programs; it explains when claims will be denied or paid and applies to providers billing Anthem in New York.
Added language permitting payment for hospital, nursing home, or home healthcare provider services for up to 30 days after the date of exclusion for clients admitted prior to the exclusion or whose plan of care was implemented prior to the exclusion.
Added language permitting payment for the first claim(s) submitted by or on behalf of a dispensing provider after the date of exclusion for up to 20 days following notice to the dispensing provider.
Sanctioned Provider Coverage
Sanctioned Provider Coverage Criteria
Coverage stance for services provided by sanctioned (excluded or debarred) providers, with limited exceptions:
Exceptions (one or more may apply)
- Hospital, nursing home, or home health payments will be made for up to 30 days after the date of exclusion for clients who were admitted prior to the exclusion or whose plan of care was implemented prior to the exclusion.
- The health plan may pay the first claim(s) submitted by or on behalf of a dispensing provider for care, services, or supplies ordered or prescribed by an excluded person after the date of exclusion, with the dispensing provider notified; no payment will be made for any care, services, or supplies ordered or prescribed by an excluded person more than 20 days after the date of notice of exclusion to the dispensing provider.
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