The clinical editing rationale supporting this database is provided here to assist you in understanding the ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Large Group 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. endstream endobj 452 0 obj <. 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. Medicaid Behavioral/Physical Health Coordination. 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. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. The latest edition and archives of our monthly provider newsletter. 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. Independent licensees of the Blue Cross and Blue Shield Association. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q . 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. Nov 1, 2021 We look forward to working with you to provide quality services to our members. 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. Access the BH Provider Manuals, Rates and Resources webpage here. Forms and information about behavioral health services for your patients. Please refer to the criteria listed below for genetic testing. 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). 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. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. Electronic authorizations. Referencing the . If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. Expedited fax: 888-235-8390. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. HealthKeepers, Inc. recommends submitting prior authorization requests for Anthem HealthKeepers Plus members via Interactive Care Reviewer (ICR), a secure Utilization Management tool available in Availity. Drug list/Formulary inclusion does not infer a drug is a covered benefit. In Maine: Anthem Health Plans of Maine, Inc. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Third-Party Liability (TPL) Forms. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. This step will help you determine if prior authorization may be required for a specific member and service. In Ohio: Community Insurance Company. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Medical Clearance Forms and Certifications of Medical Necessity. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Providers are responsible for verifying prior authorization requirements before services are rendered. 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. 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. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. 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. For costs and complete details of the coverage, please contact your agent or the health plan. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 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 You may also view the prior approval information in the Service Benefit Plan Brochures. Prior Authorization. Anthem offers great healthcare options for federal employees and their families. 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. Future updates regarding COVID-19 will appear in the monthly Provider News publication. 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. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . The latest edition and archives of our quarterly quality newsletter. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. In Kentucky: Anthem Health Plans of Kentucky, Inc. To get started, select the state you live in. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. Type at least three letters and well start finding suggestions for you. Drug list/Formulary inclusion does not infer a drug is a covered benefit. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. 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. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans 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. 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 Musculoskeletal (eviCore): 800-540-2406. Providers should continue to verify member eligibility and benefits prior to rendering services. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. 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 Select Auth/Referral Inquiry or Authorizations. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. Rx Prior Authorization. Long-Term Care (LTC) Forms. (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. 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 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. Administrative. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. State & Federal / Medicare. These manuals are your source for important information about our policies and procedures. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. endstream endobj startxref To view this file, you may need to install a PDF reader program. 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. BCBS FEP Vision covers frames, lenses, and eye exams. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. Code pairs reported here are updated quarterly based on the following schedule. Information to help you maximize your performance in our quality programs. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. You can also check status of an existing request and auto-authorize more than 40 common procedures. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Inpatient services and nonparticipating providers always require prior authorization. Independent licensees of the Blue Cross Association. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. In Maine: Anthem Health Plans of Maine, Inc. 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. ). Most PDF readers are a free download. Medical Injectable Drugs: 833-581-1861. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. 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. The coverage, please contact your agent or the Health Plan to Medi-Cal. Can also check status of an existing request and auto-authorize more than 40 common procedures together one!, use the PriorAuthorizationLookupTool or reference the provider manual to determine if prior authorization.. Alliance EPO 2022 prior authorization drug list this list was updated with 14 new codes effective Jan. 1 2022... Commercial specialty Pharmacy prior authorization requirements codes within certain categories may have been updated H2Xb R H. 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