In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), whichunderwrites or administersthe PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation (Compcare) underwritesor administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers Well Priority HMO or POS policies. In Indiana: Anthem Insurance Companies, Inc. Noncompliance with new requirements may result in denied claims. Online - The AIM ProviderPortal is available 24x7. February 2023 Anthem Provider News - Missouri, New ID cards for Anthem Blue Cross and Blue Shield members - Missouri, Telephonic-only care allowance extended through April 11, 2023 - Missouri, January 2023 Anthem Provider News - Missouri, December 2022 Anthem Provider News - Missouri, November 2021 Anthem Provider News - Missouri. Use Availity's electronic authorization tool to quickly see if a pre-authorization is required for a medical service or submit your medical pre-authorization request. In Kentucky: Anthem Health Plans of Kentucky, Inc. Administrative. To view this file, you may need to install a PDF reader program. Please verify benefit coverage prior to rendering services. 451 0 obj
<>
endobj
Do not sell or share my personal information. We encourage providers to use You may also view the prior approval information in the Service Benefit Plan Brochures. (Note: For changes to come later this year, refer to this notice, posted Dec. 28, 2020: Commercial Prior Authorization Code Changes, Effective April 1, 2021. PPO outpatient services do not require Pre-Service Review. This tool does not reflect benefits coverage* nor does it include an exhaustive listing of all noncovered services (in other words, experimental procedures, cosmetic surgery, etc. External link You are leaving this website/app (site). We look forward to working with you to provide quality services to our members. Providers are responsible for verifying prior authorization requirements before services are rendered. This approval process is called prior authorization. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Please check your schedule of benefits for coverage information. Enhanced Care Management (ECM) under CalAIM is a care management benefit that is community-based and provides a whole person approach to care that addresses the clinical and nonclinical needs of members with the most complex medical and social needs. Medical Injectable Drugs: 833-581-1861. 2022 Standard Pre-certification list . Create your signature and click Ok. Press Done. This article offers an overview of 2021 prior authorization support materials and related communications that may apply for some of our non-HMO commercial and government programs members, effective Jan. 1, 2021. endstream
endobj
startxref
CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. In Indiana: Anthem Insurance Companies, Inc. This includes our Medicaid Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM and Blue Cross Medicare Advantage (PPO)SM(MA PPO) members. Or Long-Term Care (LTC) Forms. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). PPO outpatient services do not require Pre-Service Review. Most PDF readers are a free download. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Medi-Cal Managed Care and Major Risk Medical Insurance Program Provider Manual. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. Rx Prior Authorization. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Commercial. Please Select Your State The resources on this page are specific to your state. Please refer to the criteria listed below for genetic testing. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . Anthem is a registered trademark of Anthem Insurance Companies, Inc. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. 494 0 obj
<>stream
Select Patient Registration from the top navigation. The services marked with an asterisk (*) only require Pre-Service Review for members enrolled in BlueChoice products if performed in an outpatient setting that is on the campus of a hospital. Contact 866-773-2884 for authorization regarding treatment. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. Prior authorization list. CareFirst Medicare Advantage requires notification/prior authorization of certain services. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Information about benefits for your patients covered by the BlueCard program. Inpatient services and nonparticipating providers always require prior authorization. Contact 866-773-2884 for authorization regarding treatment. Do not sell or share my personal information. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. These documents contain information about your benefits, network and coverage. In Ohio: Community Insurance Company. (Note: For changes to come later this year, refer to this notice, posted Dec. 31, 2020: New Prior Authorization Requirements for Advocate Aurora Health Members Will Take Effect April 1, 2021.). Use of the Anthem websites constitutes your agreement with our Terms of Use. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Please refer to the criteria listed below for genetic testing. The site may also contain non-Medicare related information. Start by choosing your patient's network listed below. The form contains important information regarding the patient's medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patient's health care plan. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. National Accounts, Posts about using health Insurance and managing your health, Collections of learning resources and links to services, For Sydney Health users connect with others and find care programs. Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items Review Choice Demonstration for Home Health Services Return to Top Anthem does not require prior authorization for treatment of emergency medical conditions. Additionally, providers can use this tool to make inquiries on previously submitted requests, regardless of how they were sent (phone, fax, ICR or another online tool). Anthem is a registered trademark of Anthem Insurance Companies, Inc. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. In Virginia, CareFirst MedPlus and CareFirst Diversified Benefits are is the business names of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). You'll also find news and updates for all lines of business. Forms and information about behavioral health services for your patients. Medicare Advantage. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. In Ohio: Community Insurance Company. Medical Clearance Forms and Certifications of Medical Necessity. Code pairs reported here are updated quarterly based on the following schedule. rationale behind certain code pairs in the database. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. Musculoskeletal (eviCore): 800-540-2406. Providers should continue to verify member eligibility and benefits prior to rendering services. Expedited fax: 888-235-8390. AIM Specialty Health (AIM) is an operating subsidiary of Anthem, Inc., an independent specialty medical benefits management company that provides utilization management services for BCBSTX. Scroll down to the table of contents. ). Mar 1, 2022 Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. For more information, please refer to the Medical Policy Reference Manual. These manuals are your source for important information about our policies and procedures. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Providers should continue to verify member eligibility and benefits prior to rendering services. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Inpatient Clinical: 800-416-9195. Type at least three letters and well start finding suggestions for you. These documents contain information about upcoming code edits. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Part B Step Therapy (204 KB) Drug step therapy is a type of prior authorization that requires one drug (or drugs) to be tried for a medical condition prior to utilizing other drugs; the steps typically require lower cost drugs or drugs with better clinical outcomes to be tried first. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. Bundling Rationale (Claims filed before Aug. 25, 2017). We look forward to working with you to provide quality services to our members. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), whichunderwrites or administersthe PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation (Compcare) underwritesor administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers Well Priority HMO or POS policies. Medicare Coverage with Anthem Medicare Information Medicare Coverage and Enrollment Turning 65 Medicare Advantage Plans: Part C Medicare Part D Plans Medicare Supplement Plans (Medigap) Dental and Vision Coverage CareCare What to Know Getting Better Care Preventive Health Find Care Medicare Caregiver Resources SupportSupport Login Registration Look up common health coverage and medical terms. Prior authorization requirement changes effective June 1, 2022 Mar 1, 2022 State & Federal / Medicare On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services (CMS) guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Fax medical prior authorization request forms to: 844-864-7853
Serving Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. February 2023 Anthem Provider News - Virginia, New ID cards for Anthem Blue Cross and Blue Shield members - Virginia, Telephonic-only care allowance extended through April 11, 2023 - Virginia, January 2023 Anthem Provider News - Virginia, December 2022 Anthem Provider News - Virginia, Medicare Advantage Providers | Anthem.com, March 2022 Anthem Provider News - Virginia, K1022 Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type. In addition, some sites may require you to agree to their terms of use and privacy policy. Code Bundling Rationale 2017 Q3 CPT Codes, Code Bundling Rationale 2017 Q2CPT Codes, Code Bundling Rationale 2017 Q1CPT Codes, Code Bundling Rationale 2016 Q4CPT Codes, Code Bundling Rationale 2016 Q3CPT Codes, Code Bundling Rationale 2016 Q2CPT Codes, Code Bundling Rationale 2016 Q1CPT Codes, Code Bundling Rationale 2015 Q4CPT Codes, Code Bundling Rationale 2015 Q3CPT Codes, Code Bundling Rationale 2015 Q2CPT Codes, Code Bundling Rationale 2015 Q1CPT Codes, Code Bundling Rationale 2014 Q4CPT Codes, Code Bundling Rationale 2014 Q3CPT Codes, Code Bundling Rationale 2014 Q2CPT Codes, Code Bundling Rationale 2014 Q1CPT Codes, Code Bundling Rationale 2013 Q4CPT Codes, Code Bundling Rationale 2013 Q3CPT Codes, Code Bundling Rationale 2013 Q2CPT Codes, Code Bundling Rationale 2013 Q1CPT Codes, Code Bundling Rationale 2012 Q4CPT Codes, Code Bundling Rationale 2012 Q3CPT Codes, Code Bundling Rationale 2012 Q2CPT Codes, Code Bundling Rationale 2012 Q1CPT Codes, Code Bundling Rationale 2011 Q4CPT Codes, Code Bundling Rationale 2011 Q3CPT Codes, Code Bundling Rationale 2011 Q2CPT Codes, Code Bundling Rationale 2011 Q1CPT Codes, Code Bundling Rationale 2010 Q4CPT Codes, Code Bundling Rationale 2010 Q3CPT Codes, Code Bundling Rationale 2010 Q2CPT Codes, Code Bundling Rationale 2010 Q1CPT Codes, 1998-document.write(new Date().getFullYear()); BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the Blue Cross Blue Shield Association. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Nov 1, 2021 Details about new programs and changes to our procedures and guidelines. Providers and staff can also contact Anthem for help with prior authorization via the following methods: Pharmacy Prior Authorization Center for Medi-Cal: *For Medicare-Medicaid Plan pharmacy requests, please contact Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) Customer Care at 855-817-5786. We look forward to working with you to provide quality service for our members. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. In Connecticut: Anthem Health Plans, Inc. This step will help you determine if prior authorization may be required for a specific member and service. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. CareFirst reserves the right to change this list at any time without notice. It clarifies a utilization management vendor change for specific members. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. CareFirst Commercial Pre-Service Review and Prior Authorization. Commercial Prior Authorization Summary and Code Lists 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Updated June 02, 2022. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . We've provided the following resources to help you understand Anthem's prior authorization process and obtain authorization for your patients when it's required. Contact will be made by an insurance agent or insurance company. Access eligibility and benefits information on the Availity Web Portal or Use the Prior Authorization Lookup Tool within Availity or Contact the Customer Care Center: Outside Los Angeles County: 1-800-407-4627 Inside Los Angeles County: 1-888-285-7801 Customer Care Center hours are Monday to Friday 7 a.m. to 7 p.m. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. There are three variants; a typed, drawn or uploaded signature. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Type at least three letters and well start finding suggestions for you. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Third-Party Liability (TPL) Forms. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. 711. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. The Blue Cross name and symbol are registered marks of the Blue Cross Association. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In the event of an emergency, members may access emergency services 24/7. In Kentucky: Anthem Health Plans of Kentucky, Inc. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. Summaries and code lists are posted as a reference to help you determine when prior authorization may be required for non-HMO government programs members. Our Interactive Care Reviewer (ICR) tool via Availity is the preferred method for submitting prior authorization requests, offering a streamlined and efficient experience for providers requesting inpatient and outpatient medical or behavioral health services for our members. Please check your schedule of benefits for coverage information. Infusion Site of Care Prior Authorization Drug List: New Codes Will Be Added, Effective Jan. 1, 2021 This notice was posted Dec. 28, 2020, to advise you of 14 new codes being added to our specialty pharmacy prior authorization drug list. FEP Medications requiring online prior authorization, Intravenous Immune Globulin (IVIG) Therapy, Stereotactic Radiosurgery Using Gamma Rays, Surprise Billing - Out-Of-Network Provider Notice, Ambulance -elective air transport only (10.0.005), Behavioral Health and Substance Use Disorder (Milliman Care Guidelines), Repetitive Transcranial Magnetic Stimulation (TMS), Inpatient Behavioral Health and Substance Use Disorder, Home health care (Criteria defined in the employer group benefit contract), Home Infusion Therapy (Criteria defined in the employer group benefit contract), Hospice (Criteria defined in the employer group benefit contract), Inpatient rehabilitation (Apollo Managed Care Physical Therapy, Occupational Therapy and Rehabilitation Care), Maternity Services- inpatient only, for stay greater than 48/96 hours (Criteria defined in the employer group benefit contract), Out-of-network services (Benefits available according to the member contract), Private Duty Nursing (Criteria defined in the employer group benefit contract), Skilled nursing facility admissions (Apollo Managed Care Physical Therapy, Occupational Therapy and Rehabilitation Care). Anthem offers great healthcare options for federal employees and their families. The latest edition and archives of our quarterly quality newsletter. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Decide on what kind of signature to create. The following summary and related prior authorization lists were posted on the Support Materials (Commercial) page the Utilization Management section of our Provider website as of Jan. 1, 2021: Commercial Communications The latest edition and archives of our monthly provider newsletter. Information to help you maximize your performance in our quality programs. Here youll find information on the available plans and their benefits. Use of the Anthem websites constitutes your agreement with our Terms of Use. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). The "Prior authorization list" is a list of designated medical and surgical services and select prescription Drugs that require prior authorization under the medical benefit. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. HealthKeepers, Inc. recommends submitting prior authorization requests for Anthem HealthKeepers Plus members via Interactive Care Reviewer (ICR), a secure Utilization Management tool available in Availity. Electronic authorizations. Future updates regarding COVID-19 will appear in the monthly Provider News publication. We also support our providers with access to information about our plans and member benefits, news and updates, training materials and guides and other helpful resources. The clinical editing rationale supporting this database is provided here to assist you in understanding the Any drugs, services, treatment, or supplies that the CareFirst medical staff determines, with appropriate consultation, to be experimental, investigational or unproven are not covered services. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. In Maine: Anthem Health Plans of Maine, Inc. CoverKids. Forms and information about behavioral health services for your patients. cost of services to the member if denied by Anthem for lack of medical necessity: (1) Procedures, equipment, and/or specialty infusio n drugs which have medically necessary criteria determined by Corporate Medical Policy or Adopted Clinical Guidelines. Prior authorization to confirm medical necessity is required for certain services and benefit plans as part of our commitment to help ensure all Blue Cross and Blue Shield of Illinois (BCBSIL) members get the right care, at the right time, in the right setting. Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Call our Customer Service number, (TTY: 711). One option is Adobe Reader which has a built-in reader. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). To get started, select the state you live in. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Blue Cross and Blue Shield of Illinois, aDivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. For your convenience, we've put these commonly used documents together in one place. Customer Care Center hours are Monday to Friday 7 a.m. to 7 p.m. After hours, verify member eligibility by calling the 24/7 NurseLine at. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Start by choosing your patient's network listed below. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply.