Anthem’s new clinical review process may disrupt payment

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Anthem Blue Cross Blue Shield (Anthem) is implementing a new prepayment clinical validation review process which could affect more than 20,000 DOs practicing in 14 states.

As noted in a June 2019 communication to network providers, Anthem stated that the new review process impacts claims submitted with modifiers 25 (significant, separately identifiable E/M service), 59 (distinct procedural service) and 57 (decision for surgery). Anatomical modifiers including left side (LT) and right side (RT) are also subject to review.

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