Facility Administrative Policy: Use of a Nonparticipating Care Provider
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Governs participating facilities' use of nonparticipating (non-contracted) care providers for services to members of self-funded (including ASO) commercial plans; describes penalties, exceptions, and billing restrictions.
Policy effective June 1, 2026 establishes an administrative penalty and potential termination for participating facilities that use nonparticipating care providers for members of self-funded (including ASO) plans.
Use of Nonparticipating Care Providers — Coverage Stance and Rules
Coverage stance and operational rules
Facilities must use participating providers for member care when possible; penalties and other actions apply when nonparticipating providers are used for self-funded/ASO members except in listed circumstances.
Penalty applies only to claims associated with members of self-funded (including ASO) plans.
Exceptions (any of the following)
- Emergency services are exempt from the penalty
- Anthem-granted prior approval for use of a nonparticipating care provider in the facility-based setting exempts the facility from penalty
- No participating care provider is available to render the same services within the same geographic area
- Rural hospitals as defined by HRSA are exempt
- Critical access hospitals as defined by CMS are exempt
- Safety-net hospitals (hospitals at or above the 75th percentile of the proportion of Medicare beneficiaries who are dually eligible for Medicare and Medicaid) are exempt
Participating facilities may contact Provider Services for a list of participating care providers via the number on the back of the member ID card.
Penalty Calculation and Billing Restrictions
| 0 | 0 codes (neutral) |
| 10% | Administrative penalty equal to 10% of the allowed amount of the facility's claims that involve the use of nonparticipating care providers |
What Participating Facilities Must Do
Prioritize participating providers; contact Provider Services and get prior approval to avoid penalties
Participating facilities must prioritize use of participating care providers for members receiving services in facility settings. If a participating facility intends to use a nonparticipating care provider, contact Provider Services (number on the member ID card) to obtain a list of participating care providers or seek Anthem prior approval to avoid penalties. Failure to follow this requirement may result in an administrative penalty (10% of the facility claim's allowed amount for self-funded/ASO members) and potential network termination; facilities may not balance bill members for the administrative penalty.
- Prioritize participating care providers for all facility-based services whenever possible. [[do not include chunk refs in body]]
- Call Provider Services (number on member ID card) to obtain a list of participating care providers.
- Obtain prior approval from Anthem before using a nonparticipating care provider in facility settings to be exempt from the penalty.
- Do not balance bill members for the administrative penalty applied to facility claims involving nonparticipating care providers.
Key Definitions
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