Why Anthem Denies Claims & What to Do
Understanding the most common Anthem/BCBS denial codes and proven strategies to overturn them
The Anthem Denial Challenge
Anthem Blue Cross Blue Shield (operating in 14 states) is known for having one of the higher denial rates among major commercial payors. While industry-wide denial rates average 10-15%, some Anthem plans can exceed 20% for certain service categories.
Understanding why Anthem denies claims—and having a systematic approach to appeals—can significantly improve your practice's revenue recovery.
The Top 10 Anthem Denial Codes
Based on data from thousands of provider claims, these are the most frequent Anthem denials:
1. CO-197: Precertification/Authorization Absent
Why Anthem Uses This
Anthem has extensive prior authorization requirements, especially for imaging, outpatient procedures, and therapy services. Authorization lists vary by state and plan type.
How to Appeal
- Submit retroactive authorization request immediately with medical records
- Emphasize emergent nature or lack of available authorization information at time of service
- Success rate: 30-40% if service was medically necessary
Prevention
Always verify authorization requirements before scheduling. Use Availity portal to check requirements by CPT code.
2. CO-29: Timely Filing Limit Exceeded
Why Anthem Uses This
Anthem's timely filing limit is 180 days from date of service (shorter than many payors). This catches many providers off guard.
How to Appeal
- Document any delays caused by Anthem (missing information requests, system issues)
- Reference state prompt-pay laws if applicable
- Success rate: 15-25% only if you have proof of Anthem-caused delays
Prevention
Submit all claims within 90 days. Track submission dates. Set up automated alerts at 150 days if claim is still pending.
3. CO-50: Non-Covered Services
Why Anthem Uses This
Service not covered under patient's specific plan benefits or deemed experimental/investigational.
How to Appeal
- Request copy of patient's Summary Plan Description (SPD)
- If service should be covered, submit appeal with plan documents and medical necessity
- For "experimental" denials, provide peer-reviewed literature supporting efficacy
- Success rate: 35-50% if service is actually covered in plan documents
4. CO-16: Claim/Service Lacks Information
Why Anthem Uses This
Missing diagnosis codes, incorrect modifiers, incomplete provider information, or other data fields.
How to Fix
- Review remittance advice for specific missing elements
- Resubmit corrected claim (not an appeal)
- Success rate: 90%+ if corrected information is submitted promptly
5. CO-B7: Benefit Maximum Reached
Common Scenarios
Therapy visit limits, chiropractic caps, and behavioral health maximums are frequent with Anthem plans.
How to Appeal
- Submit medical necessity appeal with clinical documentation
- Request exception based on severity or complexity
- Success rate: 25-40% for medically necessary services
State-Specific Anthem Differences
Anthem/BCBS policies vary significantly by state. Here are some important distinctions:
California (Blue Cross CA)
- Stricter utilization review
- More frequent site visits for BH providers
- AB 72 prompt-pay protections
New York (Empire BCBS)
- Strong state prompt-pay laws
- Mental health parity enforcement
- Different appeals process
Virginia
- Standard 180-day timely filing
- Active prior auth program
- Regional variations in coverage
Colorado
- SB 19-003 surprise billing protections
- Independent dispute resolution
- Strict mental health parity
The Anthem Appeals Process
Anthem has a structured appeals process. Success depends on following it correctly:
First-Level Appeal (Reconsideration)
- Submit within 180 days of denial
- Include: denial notice, medical records, clinical justification
- Response time: 30 days (standard) or 72 hours (urgent)
- Success rate: 40-50%
Second-Level Appeal (Peer-to-Peer Review)
- Submit within 180 days of first-level denial
- May include peer-to-peer clinical discussion
- Response time: 30 days (standard) or 72 hours (urgent)
- Success rate: 25-35%
External Review / State Appeal
- Request independent medical review through state department of insurance
- Available for medical necessity denials
- No cost to provider or patient
- Success rate: 30-40%
Best Practices for Anthem Appeals
Use Clinical Language
Frame appeals in terms of medical necessity, clinical guidelines, and patient outcomes
Include Peer-Reviewed Evidence
Reference clinical studies, practice guidelines, and medical literature
Document Everything
Keep copies of all submissions, reference numbers, and representative names
Follow Up Regularly
Call to check status every 10-14 days and document each conversation
When to Bill the Patient
After exhausting appeals, you may bill the patient if:
- Service was truly non-covered under their plan
- Patient signed an Advance Beneficiary Notice (ABN) or waiver
- You clearly communicated potential for non-payment before service
Important Warning
Be careful with balance billing. Many Anthem contracts prohibit balance billing for in-network claims. Review your provider agreement before billing patients.