Anthem’s reimbursement policy changes, effective April 1, 2026, will directly impact how providers are paid for preventive services, same-day sick visits, and screening-related care.
If your organization relies on preventive care visits as a consistent revenue stream, these updates aren’t just technical; they’re operational.
Here’s a clear breakdown of what’s changing and what you should be doing now.
Key Takeaway: Same-Day Visits Will Be Paid Differently
One of the most significant updates affects same-day preventive and sick visits under Medicare Advantage plans.
- Preventive visit: 100% reimbursement
- Sick visit (same day): 50% reimbursement
To receive reimbursement for the sick visit, Modifier 25 is required, and diagnosis codes must support both services. This also applies to preventive and wellness visit combinations.
Important exception: Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) are excluded from this rule.
Preventive Visits Now Include More Services (Bundled Reimbursement)
For commercial plans, Anthem is expanding what is considered part of a preventive visit — meaning fewer services will be reimbursed separately.
Services now bundled into preventive care include:
- Counseling services
- Medical nutrition therapy
- Screening services
- Additional other Evaluation & Management (E/M) services
- Annual gynecological exams
- Prolonged services
- Vision screenings
These services are not eligible for separate reimbursement when performed on the same day as a preventive visit.
Does Modifier 25 Still Work? Yes and No
Modifier 25 is often used to indicate a separate, significant E/M service, but its impact is changing.
Yes, it is still required to report a same-day sick visit. No, it will not override bundling rules for services included in preventive care.
Modifier 25 is still necessary, but no longer sufficient to guarantee payment.
What Providers Should Be Doing Now
With these changes now in effect, the focus shifts from preparation to active monitoring and adjustment.
1. Review Recent Claims Activity
Look at claims from April 1 forward:
- Are same-day visits reimbursing as expected?
- Are you seeing reductions or denials tied to these policies?
2. Identify Revenue Impact
Take a closer look at how these changes are affecting your bottom line. For example:
- How often are preventive and sick visits happening on the same day?
- Are services you previously billed separately now being bundled?
- Are you receiving less reimbursement for common visit types?
Even a quick review can help you spot trends early.
3. Reinforce Documentation and Coding Practices
Ensure providers and coding teams are aligned on:
- When Modifier 25 is required
- When services are no longer separately reimbursable
- Proper diagnosis coding to support distinct services
4. Adjust Scheduling and Workflow as Needed
If certain visit combinations consistently reduce reimbursement:
- Reevaluate how appointments are structured
- Consider whether separating services (when appropriate) makes sense operationally
5. Monitor Denials and Payer Feedback
Track denial trends closely:
- Are they tied to bundling rules?
- Are modifiers being rejected?
Use this data to refine processes quickly.
The Bigger Picture: A Shift Toward Bundled Care
These updates are part of a larger trend: payers are redefining what qualifies as a “separate” service.
For providers, that means less reliance on modifiers alone, greater emphasis on documentation, intent, and visit structure, and more coordination across teams.
Final Thoughts
Anthem’s 2026 reimbursement changes aren’t just about coding. They affect how care is scheduled, documented, and reimbursed.
Organizations that proactively adjust workflows and educate their teams will be better positioned to protect revenue, reduce denials, and stay compliant.
If you’re unsure how these updates will impact your practice, now is the time to evaluate your current processes and make adjustments before they take effect. If you have questions about how these updates apply to your organization, our team is here to help you evaluate your processes and identify potential revenue impacts.