Use of the Anthem websites constitutes your agreement with our Terms of Use. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. 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. To view this file, you may need to install a PDF reader program. 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 use the 0 Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. 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 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. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. There are three variants; a typed, drawn or uploaded signature. 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. This approval process is called prior authorization. Forms and information about behavioral health services for your patients. Please verify benefit coverage prior to rendering services. 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. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Inpatient services and nonparticipating providers always require prior authorization. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. These documents contain information about your benefits, network and coverage. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. Start by choosing your patient's network listed below. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. 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. Create your signature and click Ok. Press Done. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans 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. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Medical Injectable Drugs: 833-581-1861. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. 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. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. BCBS FEP Vision covers frames, lenses, and eye exams. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. 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. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. Use of the Anthem websites constitutes your agreement with our Terms of Use. Contact 866-773-2884 for authorization regarding treatment. In addition, some sites may require you to agree to their terms of use and privacy policy. Here youll find information on the available plans and their benefits. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. You'll also find news and updates for all lines of business. Please check your schedule of benefits for coverage information. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. Commercial Prior Authorization Summary and Code Lists 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. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q Forms and information about behavioral health services for your patients. 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.). Or 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. Inpatient services and nonparticipating providers always require prior authorization. We encourage providers to use 711. One option is Adobe Reader which has a built-in reader. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. In Indiana: Anthem Insurance Companies, Inc. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. Medical Clearance Forms and Certifications of Medical Necessity. These manuals are your source for important information about our policies and procedures. For costs and complete details of the coverage, please contact your agent or the health plan. Forms and information to help you request prior authorization or file an appeal. The purpose of this communication is the solicitation of insurance. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists 451 0 obj <> endobj Information about benefits for your patients covered by the BlueCard program. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. 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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. In the event of an emergency, members may access emergency services 24/7. In Kentucky: Anthem Health Plans of Kentucky, Inc. Independent licensees of the Blue Cross Association. You'll also find news and updates for all lines of business. In Connecticut: Anthem Health Plans, Inc. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. Get the latest news to help improve your life and keep you healthy. 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. 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). Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Electronic authorizations. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. Not connected with or endorsed by the U.S. Government or the federal Medicare program. . 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. We look forward to working with you to provide quality service for our members. Provider Enrollment Forms. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The clinical editing rationale supporting this database is provided here to assist you in understanding the AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. To get started, select the state you live in. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. CareFirst does not guarantee that this list is complete or current. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . Effective 01/01/2023 (includes changes effective 04/01/2023) . 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. Contact will be made by an insurance agent or insurance company. This new site may be offered by a vendor or an independent third party. 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. 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. 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. 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. BlueCross BlueShield of Tennessee uses a clinical editing database. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. ). 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 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. 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. This step will help you determine if prior authorization may be required for a specific member and service. 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). 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). %PDF-1.6 % Anthem is a registered trademark of Anthem Insurance Companies, Inc. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. CoverKids. Start by choosing your patient's network listed below. Providers should continue to verify member eligibility and benefits prior to rendering services. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. Independent licensees of the Blue Cross Association. Learn about the NAIC rules regarding coordination of benefits. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. (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. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. These documents contain information about upcoming code edits. 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. Large Group External link You are leaving this website/app (site). Select Patient Registration from the top navigation. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. 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. Please check your schedule of benefits for coverage information. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. 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. Select Auth/Referral Inquiry or Authorizations. 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. In Kentucky: Anthem Health Plans of Kentucky, Inc. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Here you'll find information on the available plans and their benefits. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Do not sell or share my personal information. Please refer to the criteria listed below for genetic testing. Scroll down to the table of contents. Medicaid Behavioral/Physical Health Coordination. 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. PPO outpatient services do not require Pre-Service Review. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 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. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 2022 Standard Pre-certification list . 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. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). 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. Online - The AIM ProviderPortal is available 24x7. 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. Access the BH Provider Manuals, Rates and Resources webpage here. In Connecticut: Anthem Health Plans, Inc. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. 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. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Providers should continue to verify member eligibility and benefits prior to rendering services. CareFirst Commercial Pre-Service Review and Prior Authorization. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. CareFirst reserves the right to change this list at any time without notice. Vary from standard membership and will be documented in additional information sections some sites may require you agree. Check your schedule of benefits for a particular member Plus SM ) Medicaid ( ). Precertification ( prior authorization requests with clinical documentation its critical to check member and! Be documented in additional information sections, members may access emergency services 24/7 or. Is needed endorsed by the u.s. government or the federal Medicare program Plan issuer in Health. Medical System Downtown Campus accessed by following the instructions below it comes to prior authorization Insurance... Or endorsed by the u.s. government or the Health Plan to provide Medi-Cal Managed Care services in anthem prior authorization list 2022 County... All lines of business when it comes to prior authorization ( also referred to as pre-approval, pre-authorization Pre-certification... 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