CommercialAdministrativeMedium impact
[California] Independent FFS physicians: what PPO providers need to know
Anthem BCBS·CA·Provider Bulletin
Effective date
Jul 29, 2026
We identified it
Jul 30, 2026
Summary
Anthem Blue Cross has introduced an Independent FFS care model for Pathway HMO members allowing them to receive care from PPO network providers. Billing teams must bill these claims on an FFS basis using the same PPO fee schedule, include authorization numbers when required, and ensure specialty referrals are obtained (except for behavioral health and non-referral services). Ending a PPO agreement will affect participation in the Pathway HMO network.
Action Required
Immediately: (1) Billing team must verify member eligibility and plan type before each service to identify Independent FFS Pathway HMO members versus standard PPO members. (2) For Independent FFS claims, bill using standard FFS procedures identical to PPO billing—do not change billing methodology. (3) When processing claims, ensure authorization numbers are captured and included on claims when authorization is required per the member's benefit plan. (4) Front desk and clinical staff must identify which services require specialty referrals by reviewing each member's specific Pathway HMO benefit plan documentation; confirm that behavioral health and services exempt from referral requirements per the benefit plan are flagged appropriately. (5) Update internal documentation to clarify that PPO agreement termination affects Pathway HMO network participation. (6) Establish workflow to direct eligibility questions and authorization issues to Anthem's utilization management line (866-757-8211) or behavioral health management (800-274-7767). Failure to obtain required authorizations or verify eligibility may result in claim denials or payment delays.