August 2026: Navigating Anthem Prepayment Reviews in California
Anthem Just Put You on Pre-payment Review. Now What?
This month’s ROC Masterminds meeting tackled one of the most pressing operational challenges facing behavioral health providers right now: prepayment reviews by Anthem, with a spotlight on developments in California. While we centered the conversation on Anthem’s California practices, the strategies discussed apply equally well to providers facing similar payer behavior in other states.
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What’s Happening
Providers across California are increasingly being placed into prepayment review status with Anthem — meaning claims are held and scrutinized before payment, rather than reviewed after the fact. The Hansei team walked us through what this actually looks like on the ground: delayed payments, mounting administrative requests, and inconsistent (or missing) communication from the payer about what’s actually needed to resolve a claim.
To make the process tangible, ROC ran through a real-world style scenario: a treatment center receives a prepayment review letter out of the blue and isn’t sure what to do next. Walking through it step by step, we covered the immediate next steps — who to loop in, what documentation to gather, and how to avoid common missteps that stall the process even further.
Know Your Rights as a Provider
As a provider, you have more leverage than they often realize. Key points we covered:
You’re entitled to specifics. Providers have the right to know exactly what deficiency or documentation gap is holding up a claim — not just a vague denial.
Understand your plan type. The rules and protections available differ depending on whether a claim falls under state-regulated plans versus other plan types, which affects whether the Department of Managed Health Care (DMHC) can step in.
Timely payment is a right, not a courtesy. Prompt-pay laws exist for a reason, and providers shouldn’t hesitate to invoke them.
We also discussed a real pattern we’ve seen at Hansei: claims denied over missing administrative paperwork rather than actual clinical/medical documentation issues — and why it’s worth pushing back rather than assuming the denial is final.
Getting the Documentation Right
A big chunk of our conversation focused on the practical side of surviving a prepayment review:
Submission method matters. The Availity portal was recommended over mail or fax specifically because it provides tracking and confirmation — critical when you may need to prove what was submitted and when.
Don’t over-submit. Repeatedly resending the same records without a clear reason can create more confusion, not less. Documentation should be targeted and complete the first time.
Watch for trends. Providers were encouraged to track patterns in what’s being flagged or denied, since spotting a trend early makes it easier to address the root issue instead of fighting the same battle claim by claim.
Escalating to the DMHC
When providers hit a wall with Anthem directly, it was emphasized that the Department of Managed Health Care is a real and underused resource. Filing a formal complaint — and documenting it well — creates a paper trail that matters for both the individual provider and the broader effort to hold payers accountable. Building a working relationship with DMHC investigators over time was highlighted as especially valuable, since collaboration tends to move issues forward faster than one-off complaints.
The Bigger Picture
It’s important not to sugarcoat it: prepayment reviews can significantly strain cash flow, especially for providers where Anthem accounts for a large share of their payer mix. There was honest discussion about whether things might get harder before they get better — but the consensus was clear: the path forward is persistence, documentation, and collaboration. Filing complaints, tracking patterns, and staying engaged with regulatory bodies isn’t just about resolving one claim — it’s how the industry pushes back on unfair practices at scale.
We hope to see you at our next ROC sessions throughout the year, as we remain committed to sharing updates on the status of Anthem prepayment review issues and any movement from the DMHC.