Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). For more information, please refer to the Medical Policy Reference Manual. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. You'll also find news and updates for all lines of business. Prior authorization list. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Do not sell or share my personal information. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. 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. (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.). The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. In Maine: Anthem Health Plans of Maine, Inc. Please check your schedule of benefits for coverage information. Noncompliance with new requirements may result in denied claims. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. 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. In Kentucky: Anthem Health Plans of Kentucky, Inc. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. Contact 866-773-2884 for authorization regarding treatment. Please refer to the criteria listed below for genetic testing. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. External link You are leaving this website/app (site). Phone - Call the AIM Contact Center at 866-455-8415, Monday through Friday, 6 a.m. to 6 p.m., CT; and 9 a.m. to noon, CT on weekends and holidays. Please note: This change is not applicable to the members enrolled in the Mercy Co-worker Plan as they have a customized prior authorization list. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. 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. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. 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. 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. Long-Term Care (LTC) Forms. Anthem does not require prior authorization for treatment of emergency medical conditions. endstream endobj 452 0 obj <. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. CareFirst Commercial Pre-Service Review and Prior Authorization. Access the BH Provider Manuals, Rates and Resources webpage here. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Scroll down to the table of contents. Pharmacy Forms. In Ohio: Community Insurance Company. There are three variants; a typed, drawn or uploaded signature. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . Please verify benefit coverage prior to rendering services. 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. 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. Information to help you maximize your performance in our quality programs. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. 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. To view this file, you may need to install a PDF reader program. 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. BlueCross BlueShield of Tennessee uses a clinical editing database. With three rich options to choose from, weve got you covered. Prior Authorization. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. 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. You can also refer to the provider manual for information about services that require prior authorization. endstream endobj startxref In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. To request or check the status of a prior authorization request or decision for a particular plan member, access our Interactive Care Reviewer (ICR) tool via Availity. Look up common health coverage and medical terms. Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2022. 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. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). 2005 - 2022 copyright of Anthem Insurance Companies, Inc. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. This approval process is called prior authorization. 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. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Providers should continue to verify member eligibility and benefits prior to rendering services. 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. The following summaries and related prior authorization lists were posted on the Support Materials (Government Programs) page as of Jan. 1, 2021: Important Reminder: Check Eligibility and Benefits First Please verify benefit coverage prior to rendering services. 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 The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. We look forward to working with you to provide quality services to our members. Medicaid Behavioral/Physical Health Coordination. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Expedited fax: 888-235-8390. 2022 Standard Pre-certification list . Healthcare Effectiveness Data and Information Set (HEDIS), Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Anthem HealthKeepers Plus Provider Manual, Long-term Services and Supports Authorization Guide. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 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. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. Here youll find information on the available plans and their benefits. For your convenience, we've put these commonly used documents together in one place. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Independent licensees of the Blue Cross and Blue Shield Association. Do not sell or share my personal information. 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). Select Patient Registration from the top navigation. The site may also contain non-Medicare related information. In 2020, Part B step therapy may apply to some categories . This list contains notification/prior authorization requirements for inpatient and outpatient services. 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 Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. You can also check status of an existing request and auto-authorize more than 40 common procedures. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). You'll also find news and updates for all lines of business. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . Independent licensees of the Blue Cross Association. CareFirst reserves the right to change this list at any time without notice. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. Please refer to the criteria listed below for genetic testing. Here you'll find information on the available plans and their benefits. Providers should call the prior authorization number on the back of the member ID card. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Inpatient services and nonparticipating providers always require prior authorization. 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. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Forms and information to help you request prior authorization or file an appeal. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. We look forward to working with you to provide quality service for our members. 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. %PDF-1.6 % This tool is for outpatient services only. CareFirst Medicare Advantage requires notification/prior authorization of certain services. Type at least three letters and well start finding suggestions for you. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. Code pairs reported here are updated quarterly based on the following schedule. Online - The AIM ProviderPortal is available 24x7. Please Select Your State The resources on this page are specific to your state. Rx Prior Authorization. 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. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. The prior authorization information in this notice does not apply to requests for HMO members. 711. Learn about the NAIC rules regarding coordination of benefits. 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. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 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. This step will help you determine if prior authorization may be required for a specific member and service. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Medicare Advantage. In the event of an emergency, members may access emergency services 24/7. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Electronic authorizations. . BCBS FEP Vision covers frames, lenses, and eye exams. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Decide on what kind of signature to create. CoverKids. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. State & Federal / Medicare. Providers should continue to verify member eligibility and benefits prior to rendering services. In Connecticut: Anthem Health Plans, Inc. 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. The purpose of this communication is the solicitation of insurance. Choose My Signature. One option is Adobe Reader which has a built-in reader. 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. Prior Authorization Requirements. 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. Inpatient services and nonparticipating providers always require prior authorization. Use of the Anthem websites constitutes your agreement with our Terms of Use. Prior Authorization for Some Commercial Members Will Transition from eviCore to AIM, Effective Jan. 1, 2021 This notice was posted Oct. 1, 2020, to alert you of a utilization management vendor change. Start by choosing your patient's network listed below. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Fax medical prior authorization request forms to: 844-864-7853 Most PDF readers are a free download. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. For costs and complete details of the coverage, please contact your agent or the health plan. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q 0 Mar 1, 2022 Prior Authorization (Nonpharmacy) Provider Correspondence Forms. It clarifies a utilization management vendor change for specific members. Forms and information about behavioral health services for your patients. Large Group 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. Please use the 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. In Indiana: Anthem Insurance Companies, Inc. 844-912-0938 Email: OhioMedicaidProvider@anthem.com Prior authorization resources and contact information Services Requiring Prior Authorization Inpatient prior authorization fax numbers Physical health: 877-643-0671 Behavioral health: 866-577-2184 Medicaid prior authorization: 800-964-3627 Outpatient prior authorization fax numbers For your convenience, we've put these commonly used documents together in one place. Updated June 02, 2022. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Select Auth/Referral Inquiry or Authorizations. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. 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. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. 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. In the event that the emergency room visit results in the members admission to the hospital, providers must contact Anthem within one business day following admission or post-stabilization. Administrative. To learn more about required Colorado timelines for decisions regarding PA requests, please click, The Colorado Prescription Drug Prior Authorization Request form, The New Hampshire Prescription Drug Uniform Prior Authorization Request Form. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. 477 0 obj <>/Filter/FlateDecode/ID[<530E5E682DBDAA468541E11BFAD96BAD>]/Index[451 44]/Info 450 0 R/Length 122/Prev 255106/Root 452 0 R/Size 495/Type/XRef/W[1 3 1]>>stream We encourage providers to use 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 Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. Details about new programs and changes to our procedures and guidelines. 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. Type at least three letters and well start finding suggestions for you. Third-Party Liability (TPL) Forms. 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. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Effective 01/01/2023 (includes changes effective 04/01/2023) . Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. 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 Contact Information Providers and staff can also contact Anthem for help with prior authorization via the following methods: Utilization Management (UM) for Medi-Cal Managed Care (Medi-Cal) Phone: 1-888-831-2246 Hours: Monday to Friday, 8 a.m. to 5 p.m. Fax: 1-800-754-4708 Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. 451 0 obj <> endobj Create your signature and click Ok. Press Done. Please check your schedule of benefits for coverage information. 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