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. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. The latest edition and archives of our monthly provider newsletter. 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. 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. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Do not sell or share my personal information. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. 451 0 obj <> endobj We encourage providers to use PPO outpatient services do not require Pre-Service Review. Please refer to the criteria listed below for genetic testing. Decide on what kind of signature to create. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. Independent licensees of the Blue Cross Association. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. Anthem does not require prior authorization for treatment of emergency medical conditions. Scroll down to the table of contents. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. 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. Commercial Prior Authorization Summary and Code Lists 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 2005 - 2022 copyright of Anthem Insurance Companies, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. 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. Inpatient services and nonparticipating providers always require 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. Select Auth/Referral Inquiry or Authorizations. Availity provides administrative services to BCBSIL. 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). Online - The AIM ProviderPortal is available 24x7. 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. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. Please verify benefit coverage prior to rendering services. These documents contain information about your benefits, network and coverage. 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. 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. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. 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 Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. 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 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. Some procedures may also receive instant approval. For costs and complete details of the coverage, please contact your agent or the health plan. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Use of the Anthem websites constitutes your agreement with our Terms of Use. The site may also contain non-Medicare related information. Effective 01/01/2023 (includes changes effective 04/01/2023) . BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Please check your schedule of benefits for coverage information. You'll also find news and updates for all lines of business. Home Health/Home Infusion Therapy/Hospice: 888-567-5703. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Please refer to the criteria listed below for genetic testing. Medical Clearance Forms and Certifications of Medical Necessity. This new site may be offered by a vendor or an independent third party. Prior authorization list. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . This approval process is called prior authorization. Start by choosing your patient's network listed below. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans To get started, select the state you live in. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. In Indiana: Anthem Insurance Companies, Inc. We look forward to working with you to provide quality services to our members. Forms and information about behavioral health services for your patients. 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. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). Medicaid Behavioral/Physical Health Coordination. 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. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 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. The clinical editing rationale supporting this database is provided here to assist you in understanding the 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. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. Access the BH Provider Manuals, Rates and Resources webpage here. . Bundling Rationale (Claims filed before Aug. 25, 2017). The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. 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. This list contains notification/prior authorization requirements for inpatient and outpatient services. Code pairs reported here are updated quarterly based on the following schedule. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. Please use the Choose My Signature. Nov 1, 2021 These documents contain information about upcoming code edits. Musculoskeletal (eviCore): 800-540-2406. 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. Providers should continue to verify member eligibility and benefits prior to rendering services. BCBS FEP Vision covers frames, lenses, and eye exams. 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. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Pharmacy Forms. 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. Noncompliance with new requirements may result in denied claims. 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. 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. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Medicare Advantage. Long-Term Care (LTC) Forms. The purpose of this communication is the solicitation of insurance. 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. Referencing the . Please Select Your State The resources on this page are specific to your state. 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. In Connecticut: Anthem Health Plans, Inc. ). 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 0 Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 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 Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. 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. 711. Fax medical prior authorization request forms to: 844-864-7853 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. 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. Inpatient services and nonparticipating providers always require prior authorization. Here youll find information on the available plans and their benefits. Information about benefits for your patients covered by the BlueCard program. In Maine: Anthem Health Plans of Maine, 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. 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. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. CareFirst reserves the right to change this list at any time without notice. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. In Maine: Anthem Health Plans of Maine, Inc. 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. In addition, some sites may require you to agree to their terms of use and privacy policy. Details about new programs and changes to our procedures and guidelines. Type at least three letters and well start finding suggestions for you. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. External link You are leaving this website/app (site). 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 Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. (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.). We look forward to working with you to provide quality services to our members. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Most PDF readers are a free download. In Kentucky: Anthem Health Plans of Kentucky, Inc. 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. 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. Large Group One option is Adobe Reader which has a built-in reader. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. 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. 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. Create your signature and click Ok. Press Done. rationale behind certain code pairs in the database. Expedited fax: 888-235-8390. Providers are responsible for verifying prior authorization requirements before services are rendered. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Information to help you maximize your performance in our quality programs. Anthem offers great healthcare options for federal employees and their families. Administrative. 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. Medical Injectable Drugs: 833-581-1861. Look up common health coverage and medical terms. Commercial. 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. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. In Ohio: Community Insurance Company. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. 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. Electronic authorizations. Select Patient Registration from the top navigation. This step will help you determine if prior authorization may be required for a specific member and service. Prior Authorization. Call our Customer Service number, (TTY: 711). The latest edition and archives of our quarterly quality newsletter. 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 The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem offers great healthcare options for federal employees and their families. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here.

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