CurrentBlue Cross Blue Shield - MainePolicy G-06001

Eligible Billed Charges, Reimbursement Policy

Governs reimbursement of eligible billed charges for Anthem Medicare Advantage and describes conditions under which services are eligible for reimbursement; affects participating and non-participating professional providers and facilities serving Anthem Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyEligible Billed Charges, Reimbursement Policy

Policy CodePolicy G-06001

Change TypeReview — no material changes

Effective DateNov 4, 2024

Next Review Date

Key ActionConfirm authorization requirements are met before submitting claims for reimbursement.

SourceLink

POLICY UPDATE CHANGES

11/15/2024, Policy History = Review approved and effective: no changes.

05/16/2022, template updated, moved the definition of Eligible Charges to definition section.

G-06001Policy identifier

2024-11-04Effective / Last approval date

Participating & non-participatingProvider applicability

Member/provider eligibility, benefit, authsEligibility conditions

Items provided freeExclusions

Eligibility and Coverage Conditions

Eligibility conditions

Anthem Medicare Advantage allows reimbursement of eligible charges when the following conditions are met:

ALL of the following

Member and provider eligibility
- Member program eligibility
- Provider program eligibility
Benefit coverage
Authorization requirements

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyEligible Billed Charges, Reimbursement Policy

Policy CodePolicy G-06001

Change TypeReview — no material changes

Effective DateNov 4, 2024

Next Review Date

Key ActionConfirm authorization requirements are met before submitting claims for reimbursement.

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.

Accepted Codes and Documentation Requirements

Accepted code setsmixed

CPT	Use Current Procedural Terminology codes for claims
HCPCS	Use Healthcare Common Procedure Coding System codes for claims
Revenue	Use revenue codes when appropriate

Coding support requirement

RequirementServices should be billed with CPT, HCPCS, and/or revenue codes and, when billed, must be fully supported in the medical record and/or office notes.

Consequence of noncomplianceIf appropriate coding/billing guidelines or current reimbursement policies are not followed, the claim may be rejected or denied, and payment may be recovered/recouped.

ScopeApplies to both participating and non‑participating professional providers and facilities unless otherwise noted in the policy.

PurposeEnsure submitted procedure/service codes accurately reflect services performed and are documented to support reimbursement decisions.

Authorization and Provider Responsibilities

Prior Authorization

Authorization requirement

Eligibility for reimbursement of the billed service is dependent on the application of authorization requirements as one of several conditions; reimbursement is allowed only when those authorization requirements (along with member and provider eligibility, benefit coverage, and other listed conditions) are met.

Authorization requirements are explicitly listed as a condition for eligibility for reimbursement.
Failure to meet authorization requirements may render the billed charge ineligible for reimbursement.

Key Definitions

Eligible Charges

DefinitionCharges billed by the provider that are subject to conditions and requirements that make the service eligible for reimbursement.

Conditions for eligibilityMember program eligibility; provider program eligibility; benefit coverage; authorization requirements; provider manual guidelines; administrative, clinical, and reimbursement policies; and code editing logic.

Allowed amount basisThe allowed reimbursement amount is based on the applicable fee schedule or contracted/negotiated rate after applying coinsurance, copayments, deductibles, and coordination of benefits.

ExclusionsItems the provider receives or provides to the member free of charge will not be reimbursed.