Please refer to the criteria listed below for genetic testing. Rx Prior Authorization. The clinical editing rationale supporting this database is provided here to assist you in understanding the Or A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Nov 1, 2021 The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. In Connecticut: Anthem Health Plans, Inc. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. 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. There are three variants; a typed, drawn or uploaded signature. 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). 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. This approval process is called prior authorization. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. BCBS FEP Vision covers frames, lenses, and eye exams. 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. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. As your health needs evolve, our diverse plans are designed to evolve with you. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. 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). Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. Code pairs reported here are updated quarterly based on the following schedule. 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. Benefits will be determined once a claim is received and will be based upon, among other things, the members eligibility and the terms of the members certificate of coverage applicable on the date services were rendered. Commercial. Long-Term Care (LTC) Forms. Scroll down to the table of contents. PPO outpatient services do not require Pre-Service Review. These documents contain information about upcoming code edits. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. We look forward to working with you to provide quality services to our members. You'll also find news and updates for all lines of business. 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 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. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. Please verify benefit coverage prior to rendering services. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Not connected with or endorsed by the U.S. Government or the federal Medicare program. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. 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 In Maine: Anthem Health Plans of Maine, Inc. 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. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 2022 Standard Pre-certification list . Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Community Supports under CalAIM are voluntary wrap-around services or settings available to members as a substitute for utilization of other services that focus on medical and/or needs that arise from social determinants of health. Independent licensees of the Blue Cross and Blue Shield Association. 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. Providers should continue to verify member eligibility and benefits prior to rendering services. The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Get the latest news to help improve your life and keep you healthy. ). Independent licensees of the Blue Cross Association. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Noncompliance with new requirements may result in denied claims. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 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. 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 From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Select Patient Registration from the top navigation. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. Please Select Your State The resources on this page are specific to your state. Type at least three letters and well start finding suggestions for you. Providers are responsible for verifying prior authorization requirements before services are rendered. For your convenience, we've put these commonly used documents together in one place. You'll also find news and updates for all lines of business. Most PDF readers are a free download. 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. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Commercial Prior Authorization Summary and Code Lists 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 Anthem does not require prior authorization for treatment of emergency medical conditions. The site may also contain non-Medicare related information. 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. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. Prior authorization list. 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. Expedited fax: 888-235-8390. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. 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. 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. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. 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. Learn about the NAIC rules regarding coordination of benefits. 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. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. With three rich options to choose from, weve got you covered. 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. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. 494 0 obj <>stream Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. You can also refer to the provider manual for information about services that require prior authorization. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. For costs and complete details of the coverage, please contact your agent or the health plan. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). The latest edition and archives of our quarterly quality newsletter. Choose My Signature. Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the shared business name of CareFirst Advantage, Inc. and CareFirst Advantage DSNP, Inc. CareFirst BlueCross BlueShield Community Health Plan Maryland is the business name of CareFirst Community Partners, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Updated June 02, 2022. CareFirst reserves the right to change this list at any time without notice. This approval process is called prior authorization. This step will help you determine if prior authorization may be required for a specific member and service. 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. 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. 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. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) 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. External link You are leaving this website/app (site). 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. Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. 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). We look forward to working with you to provide quality services to our members. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. Pharmacy Forms. The Blue Cross name and symbol are registered marks of the Blue Cross Association. For your convenience, we've put these commonly used documents together in one place. Effective 01/01/2023 (includes changes effective 04/01/2023) . Forms and information to help you request prior authorization or file an appeal. Bundling Rationale (Claims filed before Aug. 25, 2017). Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. To get started, select the state you live in. 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. Access the BH Provider Manuals, Rates and Resources webpage here. Some procedures may also receive instant approval. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Prior Authorization Requirements. 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. Independent licensees of the Blue Cross Association. Health Equity and Social Determinants of Health (SDoH), Over the Counter Equivalent Exclusion Program, Prior Authorization and Step Therapy Programs, Consolidated Appropriations Act & Transparency in Coverage, Medical Policy/Pre-certification: Out-of-area Members, 2021 Commercial Prior Authorization Requirements Summary, 2021 Commercial Outpatient Medical Surgical Prior Authorization Code List, 2021 Commercial Specialty Pharmacy Prior Authorization Drug List, 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List, New Prior Authorization Requirements for Some Custom Account Members Will Take Effect Jan. 1, 2021, 2021 Medicaid Prior Authorization Requirements Summary, 2021 Medicaid Prior Authorization Code List, 2021 MA PPO Prior Authorization Requirements Summary, 2021 MA PPO Prior Authorization Code List, BCBSIL Provider Network Consultant (PNC) team, Update: Utilization Management Change for Advocate Aurora Health Members, Effective Jan. 1, 2021 This News and Updates was posted Dec.15, 2020, and updated Dec. 31, 2020 to reflect a corrected phone number. & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate responsible for prior! 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