CurrentAnthemPolicy C-22002

Transitional Care Management - Professional

Defines Anthem's reimbursement stance for Transitional Care Management (TCM) professional services following discharge to community settings and describes the covered discharge/transition locations and service period. Applies to Anthem commercial plans where contract/state/federal rules allow.

Policy Summary

PayerAnthem

PolicyTransitional Care Management - Professional

Policy CodePolicy C-22002

Change TypeRoutine review — no material changes

Effective DateApr 27, 2022

Next Review Date

Key ActionFollow authorization and medical necessity guidelines appropriate to the procedure and diagnosis; services must meet applicable contract and legal requirements.

SourceLink

POLICY UPDATE CHANGES

05/22/2024 review approved: no changes.

29 daysTCM service period after discharge

30 daysDefinition reference period

2 business daysInitial contact window

14 daysFace-to-face window (99495)

7 daysFace-to-face window (99496)

Transitional Care Management Coverage Criteria

TCM coverage criteria

Anthem reimburses Transitional Care Management (TCM) professional services when provided following discharge to a member community setting and when CPT requirements are met.

TCM reimbursement conditions

Eligible discharge settings: Service provided following discharge from one of the following: Inpatient Hospital; Acute Hospital; Rehabilitation Hospital; Long-Term Acute Care Hospital; Partial Hospital; Observation status in a hospital; Skilled Nursing Facility; Nursing Facility; Emergency Room
Eligible transition destinations: Transition to a member community setting: Member's home; Domiciliary; Rest Home; Assisted Living Facility
Service period: TCM service period begins at the member's discharge and continues for 29 days

Policy Summary

PayerAnthem

PolicyTransitional Care Management - Professional

Policy CodePolicy C-22002

Change TypeRoutine review — no material changes

Effective DateApr 27, 2022

Next Review Date

Key ActionFollow authorization and medical necessity guidelines appropriate to the procedure and diagnosis; services must meet applicable contract and legal requirements.

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 Codes and Timing Requirements

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 timing — CPT 99495/99496

CPT 99495 face-to-face timingFace-to-face visit must occur within 14 calendar days of discharge for CPT 99495

CPT 99496 face-to-face timingFace-to-face visit must occur within 7 calendar days of discharge for CPT 99496

ContextFace-to-face timing is a required element of the respective TCM service codes and is tied to documented MDM complexity

Initial contact timing

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

PurposeInitial contact documents transitional planning and is a required element to bill TCM codes

Supported codesThis initial contact requirement applies to CPT 99495 and 99496 as described in coding guidance

Authorization, Medical Necessity, and Billing Guidance

Prior Authorization

Authorization and medical necessity

Follow authorization and medical necessity guidelines appropriate to the procedure and diagnosis; ensure services meet applicable state, provider contract, and federal requirements which may supersede this policy.

Verify member benefit coverage and any prior authorization requirements before providing TCM services.
Use industry-standard CPT/HCPCS codes on claims and support billed services with medical record documentation.
Be aware that state law, federal law, and provider contract language take precedence over this policy.

Key Definitions

Transitional Care Management (TCM) — definition and scope

DefinitionTransitional Care Management (TCM): Management and coordination of services for medical conditions, psychosocial needs, and activities of daily living support during the post-discharge transition period

Service periodTCM service period begins at discharge and continues for 29 days (policy references a full 30-day post-discharge care/coordination period in definitions)

ScopeIncludes coordination of medical and psychosocial needs as the patient transitions back to a community setting

ApplicabilityApplies when services are provided following discharge from specified facility types to the member's community setting, unless superseded by provider, state, or federal contract requirements