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Anthem

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Anthem

Overview

Commercial BCBS plan (Elevance-owned in many states). For PM Pediatrics, most active in NY with Medicaid-line holds flowing through Anthem. For Theoria Medical, Wisconsin-side rejections are an active pain point.

Active Work / Processes

  • Par analysis requests per state — Medallion submits par analyses through Availity (not a rep channel). Each state needs its own request — earlier PMP submissions bundled “all states” into one request which blocked progress.

Pain Points / Open Issues

  • PMP par-analysis scope confusion — (2026-04-15) The par-analysis request for PMP was submitted as “all states” on a single Connecticut-routed request. Needs to be split into separate per-state requests for CA, NJ, TX, VA (NY already confirmed). Anthem also needs confirmation whether the enrollment is group vs. facility-based; Anthem is currently rejecting PMP provider submissions pending that distinction.
  • Anthem NY Medicaid dependency holds — PMP had 21 providers on Anthem NY holds; Medallion released holds the week of 2026-04-13 as Medicaid approvals came through, causing a temporary spike in PMP’s aged-line report.
  • Wisconsin GP-saturation rejection — Fareed Ahmad (Theoria) — Anthem rejected with three reasons: (1) <1 year US training, (2) <10 years clinical, (3) geographic GP saturation. Provider qualifies on (1) and (2); appears mis-categorized as GP rather than family medicine. He’s a medical director at the facility. Amy researching whether reconsideration letter or link-to-existing-group resolves it. Source: 14 Cred Hold sync.

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