Anthem Blue Cross (CA) and PCM codes (99424, 99425, 99426, 99427) non reimbursab

[Fay43]

Some of our providers do PCM services but Anthem Blue Cross (CA) has been denying these indicating no fee schedule and advised us to appeal as a pricing appeal. I cannot find a policy around PCM with them and they could not refer me to one. Does anyone else have any information on Blue Cross and these codes? We were able to find a policy for another state where they don't cover but nothing for our state. This code is not always covered by insurance (such as Cigna) so i'm thinking they may not cover it. They have paid on some of the pricing appeals but not on others.

[keithdillon219]

Anthem Blue Cross in California does not list a clear policy for PCM services, which is why claims are often denied as “no fee schedule.” Since they sometimes pay after a pricing appeal, the best solution is to continue submitting appeals with supporting documentation, as coverage can vary by case. Some insurers, like Cigna, also do not cover these codes consistently, so it is possible that Anthem has limited or no coverage. Just like merino wool is valued differently depending on quality and source, PCM services may be handled differently by each insurer, so confirming directly with Anthem and keeping records of appeal outcomes is the most reliable approach.

[CasinosStorm]

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