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). Choose My Signature. Not connected with or endorsed by the U.S. Government or the federal Medicare program. 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. 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. ANTHEM is a registered trademark of Anthem Insurance Companies, 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. Select Auth/Referral Inquiry or Authorizations. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. 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. ). Type at least three letters and well start finding suggestions for you. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Effective 01/01/2023 (includes changes effective 04/01/2023) . Anthem is a registered trademark of Anthem Insurance Companies, Inc. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. Inpatient services and nonparticipating providers always require prior authorization. Providers should call the prior authorization number on the back of the member ID card. You may also view the prior approval information in the Service Benefit Plan Brochures. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. We look forward to working with you to provide quality services to our members. 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.). Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). 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. . Contact 866-773-2884 for authorization regarding treatment. Please verify benefit coverage prior to rendering services. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. External link You are leaving this website/app (site). The latest edition and archives of our quarterly quality newsletter. 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. 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. Call our Customer Service number, (TTY: 711). 711. 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 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. Prior authorization to confirm medical necessity is required for certain services and benefit plans as part of our commitment to help ensure all Blue Cross and Blue Shield of Illinois (BCBSIL) members get the right care, at the right time, in the right setting. 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. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. PPO outpatient services do not require Pre-Service Review. Medicare Advantage. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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 451 0 obj <> endobj ICR offers a fast, efficient way to securely submit your requests with clinical documentation. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Contact 866-773-2884 for authorization regarding treatment. 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. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) You'll also find news and updates for all lines of business. This approval process is called prior authorization. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. These documents contain information about upcoming code edits. Providers should continue to verify member eligibility and benefits prior to rendering services. Forms and information about behavioral health services for your patients. In Kentucky: Anthem Health Plans of Kentucky, Inc. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Anthem offers great healthcare options for federal employees and their families. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. 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. 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. 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. Code pairs reported here are updated quarterly based on the following schedule. Do not sell or share my personal information. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Please check your schedule of benefits for coverage information. Use of the Anthem websites constitutes your agreement with our Terms of Use. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. 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. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. To get started, select the state you live in. Select Patient Registration from the top navigation. CoverKids. PPO outpatient services do not require Pre-Service Review. 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. Anthem offers great healthcare options for federal employees and their families. 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 Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. In Indiana: Anthem Insurance Companies, Inc. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Forms and information about behavioral health services for your patients. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Create your signature and click Ok. Press Done. BCBS FEP Vision covers frames, lenses, and eye exams. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. In Maine: Anthem Health Plans of Maine, Inc. CareFirst reserves the right to change this list at any time without notice. Medical Clearance Forms and Certifications of Medical Necessity. The clinical editing rationale supporting this database is provided here to assist you in understanding the In Maine: Anthem Health Plans of Maine, Inc. %PDF-1.6 % It clarifies a utilization management vendor change for specific members. Third-Party Liability (TPL) Forms. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Rx Prior Authorization. These documents contain information about your benefits, network and coverage. 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. Commercial. In Kentucky: Anthem Health Plans of Kentucky, Inc. Information about benefits for your patients covered by the BlueCard program. State & Federal / Medicare. CareFirst does not guarantee that this list is complete or current. Please check your schedule of benefits for coverage information. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. BlueCross BlueShield of Tennessee uses a clinical editing database. Most PDF readers are a free download. For your convenience, we've put these commonly used documents together in one place. Look up common health coverage and medical terms. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Details about new programs and changes to our procedures and guidelines. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. rationale behind certain code pairs in the database. Fax medical prior authorization request forms to: 844-864-7853 In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Ohio: Community Insurance Company. 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 The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. CareFirst Commercial Pre-Service Review and Prior Authorization. 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. 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. Online - The AIM ProviderPortal is available 24x7. 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. Please refer to the criteria listed below for genetic testing. There are three variants; a typed, drawn or uploaded signature. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. This tool is for outpatient services only. Forms and information to help you request prior authorization or file an appeal. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. We look forward to working with you to provide quality services to our members. (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.). Electronic authorizations. CareFirst Medicare Advantage requires notification/prior authorization of certain services. In Connecticut: Anthem Health Plans, Inc. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . 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. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. You can also refer to the provider manual for information about services that require prior authorization. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. To view this file, you may need to install a PDF reader program. 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. Contact will be made by an insurance agent or insurance company. Updated June 02, 2022. 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 Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. 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. 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 With three rich options to choose from, weve got you covered. The prior authorization information in this notice does not apply to requests for HMO members. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. 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. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. Long-Term Care (LTC) Forms. 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. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 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. These manuals are your source for important information about our policies and procedures. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. %%EOF 494 0 obj <>stream 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. Prior authorization list. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. Or For costs and complete details of the coverage, please contact your agent or the health plan. Some procedures may also receive instant approval. Please verify benefit coverage prior to rendering services. Medical Injectable Drugs: 833-581-1861. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Expedited fax: 888-235-8390. 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. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). 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. Independent licensees of the Blue Cross and Blue Shield Association. 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. 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. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. 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). Availity provides administrative services to BCBSIL. 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. You can also check status of an existing request and auto-authorize more than 40 common procedures. 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. 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. In Ohio: Community Insurance Company. Prior Authorization Requirements. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Independent licensees of the Blue Cross Association. In 2020, Part B step therapy may apply to some categories . 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. 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. 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