The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Inpatient Clinical: 800-416-9195. 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. Referencing the . 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. 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. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. Medical Clearance Forms and Certifications of Medical Necessity. 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. PPO outpatient services do not require Pre-Service Review. Use Availity's electronic authorization tool to quickly see if a pre-authorization is required for a medical service or submit your medical pre-authorization request. 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. Select Auth/Referral Inquiry or Authorizations. These documents contain information about upcoming code edits. You can also refer to the provider manual for information about services that require prior authorization. Availity provides administrative services to BCBSIL. ANTHEM is a registered trademark of Anthem Insurance Companies, 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. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Long-Term Care (LTC) Forms. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 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. Decide on what kind of signature to create. 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. Home Health/Home Infusion Therapy/Hospice: 888-567-5703. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. CareFirst Medicare Advantage requires notification/prior authorization of certain services. 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. 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. 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. Providers should call the prior authorization number on the back of the member ID card. In Ohio: Community Insurance Company. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q Musculoskeletal (eviCore): 800-540-2406. In the event of an emergency, members may access emergency services 24/7. Rx Prior Authorization. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. 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. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. 2022 Standard Pre-certification list . 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. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. 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. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). 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. Do not sell or share my personal information. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. This approval process is called prior authorization. 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. Code pairs reported here are updated quarterly based on the following schedule. Contact 866-773-2884 for authorization regarding treatment. In Indiana: Anthem Insurance Companies, Inc. For more information, please refer to the Medical Policy Reference Manual. You'll also find news and updates for all lines of business. This tool is for outpatient services only. Online - The AIM ProviderPortal is available 24x7. rationale behind certain code pairs in the database. Please refer to the criteria listed below for genetic testing. Expedited fax: 888-235-8390. In Ohio: Community Insurance Company. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Anthem offers great healthcare options for federal employees and their families. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. 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. Noncompliance with new requirements may result in denied claims. Please Select Your State The resources on this page are specific to your state. Or hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L 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. In addition, some sites may require you to agree to their terms of use and privacy policy. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. 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 Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Independent licensees of the Blue Cross and Blue Shield Association. The prior authorization information in this notice does not apply to requests for HMO members. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Here you'll find information on the available plans and their benefits. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. For your convenience, we've put these commonly used documents together in one place. Information about benefits for your patients covered by the BlueCard program. CoverKids. Medicare Advantage. 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. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Look up common health coverage and medical terms. One option is Adobe Reader which has a built-in reader. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. We look forward to working with you to provide quality service for our members. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Pharmacy Forms. 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 list may vary based on account contracts and should be verified by contacting 1-866-773-2884. 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. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. Create your signature and click Ok. Press Done. Learn about the NAIC rules regarding coordination of benefits. In Kentucky: Anthem Health Plans of Kentucky, Inc. The latest edition and archives of our quarterly quality newsletter. Start by choosing your patient's network listed below. Choose My Signature. 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. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. The purpose of this communication is the solicitation of insurance. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Select Patient Registration from the top navigation. To get started, select the state you live in. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. 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. This approval process is called prior authorization. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. CareFirst does not guarantee that this list is complete or current. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Anthem is a registered trademark of Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. The latest edition and archives of our monthly provider newsletter. 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). Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Please refer to the criteria listed below for genetic testing. With three rich options to choose from, weve got you covered. Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. BlueCross BlueShield of Tennessee uses a clinical editing database. 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. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Do not sell or share my personal information. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). You may also view the prior approval information in the Service Benefit Plan Brochures. The clinical editing rationale supporting this database is provided here to assist you in understanding the Inpatient services and nonparticipating providers always require prior authorization. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. Please check your schedule of benefits for coverage information. Type at least three letters and well start finding suggestions for you. The Blue Cross name and symbol are registered marks of the Blue Cross Association. 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 2020, Part B step therapy may apply to some categories . Independent licensees of the Blue Cross Association. Electronic authorizations. Please check your schedule of benefits for coverage information. endstream endobj 452 0 obj <. . External link You are leaving this website/app (site). 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). Get the latest news to help improve your life and keep you healthy. 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. 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. 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 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). For costs and complete details of the coverage, please contact your agent or the health plan. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. %PDF-1.6 % To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Inpatient services and nonparticipating providers always require prior authorization. We look forward to working with you to provide quality services to our members. 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. As your health needs evolve, our diverse plans are designed to evolve with you. Please verify benefit coverage prior to rendering services. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. 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. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. 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. 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. endstream endobj startxref Medical Injectable Drugs: 833-581-1861. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. This list contains notification/prior authorization requirements for inpatient and outpatient services. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. 711. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. In Connecticut: Anthem Health Plans, Inc. (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.). 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.). Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Information to help you maximize your performance in our quality programs. 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. Commercial Prior Authorization Summary and Code Lists Most PDF readers are a free download. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Future updates regarding COVID-19 will appear in the monthly Provider News publication. 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. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. 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. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. You can also check status of an existing request and auto-authorize more than 40 common procedures. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Updated June 02, 2022. In Maine: Anthem Health Plans of Maine, Inc. Third-Party Liability (TPL) Forms. 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. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. 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. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Providers should continue to verify member eligibility and benefits prior to rendering 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 Commercial. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. 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. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. CareFirst Commercial Pre-Service Review and Prior Authorization. These manuals are your source for important information about our policies and procedures. Large Group This step will help you determine if prior authorization may be required for a specific member and service. Here youll find information on the available plans and their benefits. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. In Maine: Anthem Health Plans of Maine, Inc. For your convenience, we've put these commonly used documents together in one place. 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. Forms and information about behavioral health services for your patients. The site may also contain non-Medicare related information. Not connected with or endorsed by the U.S. Government or the federal Medicare program. Type at least three letters and well start finding suggestions for you. To evolve with you to provide Medi-Cal Managed Care services in Los Angeles County services Los. Solicitation of Insurance Commissioners, Medicare Complaints, Grievances & Appeals authorization of certain.. For our members emergency services 24/7 duty family members require ordering physicians to request prior authorization for molecular genetic.... 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