Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Anthem offers great healthcare options for federal employees and their families. BCBS FEP Vision covers frames, lenses, and eye exams. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. 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 Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 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. CoverKids. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. This step will help you determine if prior authorization may be required for a specific member and service. The prior authorization information in this notice does not apply to requests for HMO members. In Indiana: Anthem Insurance Companies, Inc. Providers should continue to verify member eligibility and benefits prior to rendering 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. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Effective 01/01/2023 (includes changes effective 04/01/2023) . 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. 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. Information to help you maximize your performance in our quality programs. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . 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. 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. Large Group Forms and information to help you request prior authorization or file an appeal. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Long-Term Care (LTC) Forms. 2022 Standard Pre-certification list . View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. The site may also contain non-Medicare related information. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. 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. Type at least three letters and well start finding suggestions for you. Independent licensees of the Blue Cross Association. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. In Kentucky: Anthem Health Plans of Kentucky, Inc. 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. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Availity provides administrative services to BCBSIL. This approval process is called prior authorization. Referencing the . In Indiana: Anthem Insurance Companies, Inc. Please verify benefit coverage prior to rendering services. 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. Create your signature and click Ok. Press Done. (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.). AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. 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. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. 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. For your convenience, we've put these commonly used documents together in one place. Medical Injectable Drugs: 833-581-1861. 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. Select Auth/Referral Inquiry or Authorizations. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Or Access the BH Provider Manuals, Rates and Resources webpage here. 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. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. endstream endobj startxref 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. 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. For more information, please refer to the Medical Policy Reference Manual. We look forward to working with you to provide quality services to our members. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. CareFirst does not guarantee that this list is complete or current. Updated June 02, 2022. We look forward to working with you to provide quality service for our members. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. You can also check status of an existing request and auto-authorize more than 40 common procedures. %PDF-1.6 % 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. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. In Connecticut: Anthem Health Plans, Inc. Prior Authorization. You can also refer to the provider manual for information about services that require prior authorization. (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. Pharmacy Forms. 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 Scroll down to the table of contents. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L 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. As your health needs evolve, our diverse plans are designed to evolve with you. 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 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. Independent licensees of the Blue Cross Association. BlueCross BlueShield of Tennessee uses a clinical editing database. Drug list/Formulary inclusion does not infer a drug is a covered benefit. This list contains notification/prior authorization requirements for inpatient and outpatient services. Inpatient Clinical: 800-416-9195. 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. Choose My Signature. Details about new programs and changes to our procedures and guidelines. Inpatient services and nonparticipating providers always require prior authorization. Learn about the NAIC rules regarding coordination of benefits. These documents contain information about upcoming code edits. We look forward to working with you to provide quality services to our members. 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. Independent licensees of the Blue Cross and Blue Shield Association. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. With three rich options to choose from, weve got you covered. You may also view the prior approval information in the Service Benefit Plan Brochures. Home Health/Home Infusion Therapy/Hospice: 888-567-5703. 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. In the event of an emergency, members may access emergency services 24/7. 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. Mar 1, 2022 Decide on what kind of signature to create. 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. External link You are leaving this website/app (site). 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. Providers should call the prior authorization number on the back of the member ID card. One option is Adobe Reader which has a built-in reader. The latest edition and archives of our quarterly quality newsletter. There are three variants; a typed, drawn or uploaded signature. ). The Blue Cross name and symbol are registered marks of the Blue Cross Association. Information about benefits for your patients covered by the BlueCard program. Use of the Anthem websites constitutes your agreement with our Terms of Use. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. Most PDF readers are a free download. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. 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. 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. 451 0 obj <> endobj If you have any questions, call the number on the members ID card. Do not sell or share my personal information. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Inpatient services and nonparticipating providers always require prior authorization. Online - The AIM ProviderPortal is available 24x7. Commercial. Provider Enrollment Forms. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. 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). Plans for federal employees, retirees, retired uniformed service members, and active duty family members. State & Federal / Medicare. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. Independent licensees of the Blue Cross and Blue Shield Association. Do not sell or share my personal information. In Ohio: Community Insurance Company. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. For costs and complete details of the coverage, please contact your agent or the health plan. For your convenience, we've put these commonly used documents together in one place. Contact 866-773-2884 for authorization regarding treatment. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 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. Noncompliance with new requirements may result in denied claims. In Connecticut: Anthem Health Plans, Inc. Nov 1, 2021 Prior authorization list. 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. Contact will be made by an insurance agent or insurance company. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. Please refer to the criteria listed below for genetic testing. Providers are responsible for verifying prior authorization requirements before services are rendered. 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. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. To get started, select the state you live in. 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. 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. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. PPO outpatient services do not require Pre-Service Review. Third-Party Liability (TPL) Forms. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. 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. This new site may be offered by a vendor or an independent third party. Not connected with or endorsed by the U.S. Government or the federal Medicare program. 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.). 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. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Get the latest news to help improve your life and keep you healthy. The clinical editing rationale supporting this database is provided here to assist you in understanding the endstream endobj 452 0 obj <. Some procedures may also receive instant approval. Musculoskeletal (eviCore): 800-540-2406. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Here youll find information on the available plans and their benefits. Please use the Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. In addition, some sites may require you to agree to their terms of use and privacy policy. To get started, select the state you live in. Electronic authorizations. It clarifies a utilization management vendor change for specific members. 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). rationale behind certain code pairs in the database. 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. Bundling Rationale (Claims filed before Aug. 25, 2017). In Ohio: Community Insurance Company. 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 In Kentucky: Anthem Health Plans of Kentucky, 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. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Please check your schedule of benefits for coverage information. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. 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. Anthem offers great healthcare options for federal employees and their families. 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 latest edition and archives of our monthly provider newsletter. 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. 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. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. You'll also find news and updates for all lines of business. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. In Maine: Anthem Health Plans of Maine, Inc. 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. Medicare Advantage. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. 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