CurrentAnthemPolicy C-22002

Transitional Care Management - Professional

Defines Anthem's reimbursement policy for Transitional Care Management (TCM) professional services following discharge to a community setting and specifies eligible discharge and community settings and applicable CPT codes.

Policy Summary

PayerAnthem

PolicyTransitional Care Management - Professional

Policy CodePolicy C-22002

Change TypeClarified (no material changes)

Effective Date01/01/2026

Next Review Date

Key ActionFollow authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence; services must meet plan benefit and contract requirements.

SourceLink

POLICY UPDATE CHANGES

10/01/2025 review approved and effective 01/01/2026: no changes

29 daysTCM service period

2 business daysInitial contact timeframe

7 or 14 daysFace-to-face timeframe

99495/99496Reimbursable codes

Coverage Criteria for Transitional Care Management

Coverage criteria for Transitional Care Management

Covered when ALL of the following are met:

ALL of the following

Transitional Care Management (TCM) services are furnished upon discharge from one of the following settings:
Discharge settings (ANY)
- Inpatient hospital
- Acute hospital
- Rehabilitation hospital

Policy Summary

PayerAnthem

PolicyTransitional Care Management - Professional

Policy CodePolicy C-22002

Change TypeClarified (no material changes)

Effective Date01/01/2026

Next Review Date

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.

CPT-required elements

For CPT 99495: Communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge
For CPT 99495: Medical decision making of at least moderate complexity during the service period
For CPT 99495: Face-to-face visit within 14 calendar days of discharge
For CPT 99496: Communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge
For CPT 99496: Medical decision making of high complexity during the service period
For CPT 99496: Face-to-face visit within 7 calendar days of discharge

CPT Codes and Service Timing

TCM CPT codesCPTCovered

99495	Transitional Care Management Services: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit within 14 calendar days of discharge.
99496	Transitional Care Management Services: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of high complexity during the service period; face-to-face visit within 7 calendar days of discharge.

Face-to-face visit timeframe

99496 face-to-face timeframeFace-to-face visit must occur within 7 calendar days of discharge

99495 face-to-face timeframeFace-to-face visit must occur within 14 calendar days of discharge

Source guidanceTimeframes and code-specific requirements are defined in the Related Coding section for CPT codes 99495 and 99496

Initial communication requirement

Required initial contactDirect contact (telephone or electronic) with patient and/or caregiver within 2 business days of discharge

Permitted contact methodsTelephone or electronic communication counted as direct contact

Applies to both codesThis initial communication requirement applies to services billed as CPT 99495 and 99496

Service period length

Service period startTCM service period begins on the member's date of discharge

Service period durationContinues for 29 days from the date of discharge

ApplicabilityApplies when member transitions from specified inpatient/facility settings to a community setting

Authorization, Medical Necessity, and Billing Actions

Documentation Required

Obtain required authorization, meet medical necessity, and document/bill appropriately

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; bill TCM services with applicable CPT/HCPCS codes and ensure the medical record/office notes fully support the billed services. Failure to follow authorization, medical necessity, or proper coding/billing guidelines may result in claim rejection, denial, or recovery/recoupment of payment.

Follow authorization and medical necessity requirements appropriate to the procedure, diagnosis, and member's state of residence.
Bill services using industry-standard CPT/HCPCS codes and ensure documentation in the medical record/office notes fully supports the billed services.
Noncompliance with authorization, medical necessity, or billing guidelines may lead to claim rejection, denial, or repayment/recoupment.

OpenPayer

Transitional Care Management - Professional

Coverage Criteria for Transitional Care Management

CPT Codes and Service Timing

Authorization, Medical Necessity, and Billing Actions

Definitions