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Update to All Anthem Providers

ADA members have informed us of an increase in Anthem claims denials, beginning July 1, 2025. These denials appear to solely affect Anthem providers providing care to patients with Anthem:

  • California
  • Colorado
  • Connecticut
  • Georgia
  • Indiana
  • Kentucky
  • Maine
  • Missouri (excluding 30 counties in the Kansas City area)
  • Nevada
  • New Hampshire
  • New York
  • Ohio
  • Virginia
  • Wisconsin

ADA has been made aware that some Anthem Medicare Advantage plans throughout the US are denying claims for medically necessary, diagnostic audiologic testing. In these denials, they indicate that the claim was “misrouted” and/or “not covered by this payor/contractor”. When Anthem is contacted, they are indicating that the claim should be processed by Hearing Care Solutions, which, to our knowledge, cannot and does not process diagnostic audiologic claims, especially those providers who do not participate with Hearing Care Solutions.

There is no real consistency established yet with these denials. SOME OF YOU MAY NOT BE IMPACTED. They seem to vary by state, practice setting (private practice versus institutional practice), and specific health plan (most denials have been for Medicare Advantage claims). AS A RESULT, WE RECOMMEND THAT ALL CLAIMS FOR MEDICALLY NECESSARY AUDIOLOGIC DIAGNOSTIC SERVICES STILL BE FIRST SUBMITTED TO ANTHEM.

At this point, it DOES NOT affect Anthem providers processing out of state (non-Anthem Blue Cross Blue Sheld Association plans) or Blue Cross Blue Shield (BCBS) association providers in other states processing Anthem claims.

Medicare Advantage denials for diagnostic hearing and audiologic testing

ADA has reached out to our contacts at Anthem and TruHearing (with which Hearing Care Solutions has merged) and other stakeholders. Our legal counsel has been included in this correspondence. We are trying to get information on this change and how our members are to operationalize these decisions. We are being told that there is no expedient solution to this issue at this time.

In the interim, we are offering guidance based upon your situation:

Anthem In-network private practice providers who participate with Hearing Care Solutions (HCS)

  1. Collect all applicable unmet deductible, co-payments, and co-insurance.
  2. Submit your claims for medically necessary audiologic diagnostic testing to Anthem.
  3. If denied because “not covered by this payer/contractor, contact Hearing Care Solutions via email (this is the only email I could locate: applications@hearingcaresolutions.com) and request a process for submitting claims for diagnostic testing. DO NOT TRY TO ENTER PATIENT INTO PORTAL and DO NOT WASTE RESOURCES TRYING TO APPEAL THIS SPECIFIC COVERAGE DESION.
    • If they do not respond to email, call (303) 407-6813.
  4. Follow the process provided by HCS.
  5. Have your attorney review your Anthem contract to determine if 1) you were appropriated notified of changes to your agreement and 2) if any aspect of this change violates your contracts terms and conditions.
  6. File a complaint with Medicare Advantage outlining the situation.

Anthem In-network private practice providers who do participate with Hearing Care Solutions

  1. Consider your practice out of network for Anthem Medicare Advantage for hearing and audiologic testing.
  2. Have your patients receive a Good Faith Estimate (if scheduled more than 72 hours in advance) and a notice of non-coverage (reason for non-coverage is hearing and audiologic claims must be processed through Hearing Care Solutions and you are out of network).
  3. On the date of service, collect the Medicare Limiting Charge from the Anthem Medicare Advantage beneficiary for all medically necessary, Medicare covered audiology services.
  4. Submit a claim to Anthem Medicare Advantage and accept assignment on that claim.
  5. If the claim is denied FOR “NOT COVERED BY PAYER/CONTRACTOR”, DO NOT WASTE RESOURCES TRYING TO APPEAL THIS SPECIFIC COVERAGE DECISION. Instead, encourage your patients to file complaints with Anthem and Medicare Advantage outlining the situation.
  6. Have your attorney review your Anthem contract to determine if 1) you were appropriated notified of changes to your agreement and 2) if any aspect of this change violates your contracts terms and conditions.

Providers in Anthem states who do not participate with Anthem

  1. Have your patients receive a Good Faith Estimate (if scheduled more than 72 hours in advance) and a notice of non-coverage (reason for non-coverage is hearing and audiologic claims must be processed through Hearing Care Solutions and you are out of network).
  2. On the date of service, collect the Medicare Limiting Charge from the Anthem Medicare Advantage beneficiary for all medically necessary, Medicare covered audiology services.
  3. Submit a claim to Anthem Medicare Advantage and do not accept assignment on that claim.
  4. If the claim is denied FOR “NOT COVERED BY PAYER/CONTRACTOR”, DO NOT WASTE RESOURCES TRYING TO APPEAL THIS SPECIFIC COVERAGE DECISION. Instead, encourage your patients to file complaints with Anthem and Medicare Advantage outlining the situation.

In Anthem claim is denied for any other reason:

  1. Submit appeals for denied claims and include the following documentation:

For Denials related to a strict adherence to documented medical coverage policies
Anthem, for many years, has had well-documented medical coverage policies. They can be found here (please select the appropriate state).

There are existing coverage policies in many states that address:

  • Air conduction hearing aids.
  • Bone conduction hearing aids and implantable devices.
  • Auditory brainstem response testing.
  • Otoacoustic emissions.
  • Cochlear implants.
  • Auditory brainstem implants.
  • Intraoperative monitoring.
  • Vestibular function testing.
  • Pre-fabricated earmolds.
  • Implantable middle ear hearing aids.
  • Mobile device health management applications.

Anthem is now denying claims that do not strictly adhere to these documented coverage policies, whether you are in or out of network

What practices need to do:

  • Download all applicable coverage policies.
  • Have your entire team review these coverage policies.
  • When the diagnostic and/or care recommendation includes an item or service not covered per these policies, have the patient complete a notice of non-coverage prior to the provision of care (with a reason for non-coverage being limitations imposed by an Anthem coverage policy) and collect your usual and customary fee for the item or service.
  • Submit the claim to Anthem and refund the patient any monies paid.

As with all health plan network participation, as the end of the year approaches, audiologists should perform a Market. Financial and Strengths, Weaknesses, Opportunities Threats (SWOT) analysis on each, individual, respective managed care and hearing benefit plan and determine if continued participation is sustainable.

ADA is here to assist its members with their managed care questions and needs. Please feel free to reach out to Kim Cavitt or 773-960-6625. This guidance is a value-added benefit of ADA membership.

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