The site may also contain non-Medicare related information. The latest edition and archives of our quarterly quality newsletter. Get the latest news to help improve your life and keep you healthy. Information to help you maximize your performance in our quality programs. Pharmacy Forms. 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. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. Contact 866-773-2884 for authorization regarding treatment. Information about benefits for your patients covered by the BlueCard program. We encourage providers to use Type at least three letters and well start finding suggestions for you. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 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 Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Noncompliance with new requirements may result in denied claims. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 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. National Accounts, Posts about using health Insurance and managing your health, Collections of learning resources and links to services, For Sydney Health users connect with others and find care programs. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Select Auth/Referral Inquiry or Authorizations. 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). We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. 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. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Start by choosing your patient's network listed below. Forms and information about pharmacy services and prescriptions for your patients. Electronic authorizations. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. Here you'll find information on the available plans and their benefits. Use of the Anthem websites constitutes your agreement with our Terms of Use. State & Federal / Medicare. You can also refer to the provider manual for information about services that require prior authorization. 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 notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. Online - The AIM ProviderPortal is available 24x7. These manuals are your source for important information about our policies and procedures. 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. 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 PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. Commercial. 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. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Prior Authorization (Nonpharmacy) Provider Correspondence 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. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Providers should call the prior authorization number on the back of the member ID card. These documents contain information about your benefits, network and coverage. cost of services to the member if denied by Anthem for lack of medical necessity: (1) Procedures, equipment, and/or specialty infusio n drugs which have medically necessary criteria determined by Corporate Medical Policy or Adopted Clinical Guidelines. 494 0 obj <>stream 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. PPO outpatient services do not require Pre-Service Review. In the event of an emergency, members may access emergency services 24/7. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 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. 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 Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. External link You are leaving this website/app (site). This list contains notification/prior authorization requirements for inpatient and outpatient services. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists 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 Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. Administrative. As your health needs evolve, our diverse plans are designed to evolve with you. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. ). Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. Prior Authorization. Look up common health coverage and medical terms. 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). 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. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. Please use the . Some procedures may also receive instant approval. %%EOF One option is Adobe Reader which has a built-in reader. Here youll find information on the available plans and their benefits. Details about new programs and changes to our procedures and guidelines. This approval process is called prior authorization. Commercial Prior Authorization Summary and Code Lists Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. 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. In Kentucky: Anthem Health Plans of Kentucky, Inc. For costs and complete details of the coverage, please contact your agent or the health plan. We look forward to working with you to provide quality services to our members. Anthem does not require prior authorization for treatment of emergency medical conditions. Anthem offers great healthcare options for federal employees and their families. Fax medical prior authorization request forms to: 844-864-7853 Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. We look forward to working with you to provide quality service for our members. 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 Indiana: Anthem Insurance Companies, Inc. Providers should continue to verify member eligibility and benefits prior to rendering services. 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. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 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. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. %PDF-1.6 % The clinical editing rationale supporting this database is provided here to assist you in understanding the Medical Injectable Drugs: 833-581-1861. These documents contain information about upcoming code edits. In Indiana: Anthem Insurance Companies, Inc. 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. 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. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. In Ohio: Community Insurance Company. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. Musculoskeletal (eviCore): 800-540-2406. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. 451 0 obj <> endobj PPO outpatient services do not require Pre-Service Review. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. 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. 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. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. 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. For more information, please refer to the Medical Policy Reference Manual. For your convenience, we've put these commonly used documents together in one place. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. CareFirst Commercial Pre-Service Review and Prior Authorization. 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. CareFirst reserves the right to change this list at any time without notice. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), whichunderwrites or administersthe PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation (Compcare) underwritesor administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers Well Priority HMO or POS policies. To get started, select the state you live in. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. (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.). This new site may be offered by a vendor or an independent third party. Prior Authorization Requirements. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Independent licensees of the Blue Cross Association. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Please verify benefit coverage prior to rendering services. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. 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. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Please refer to the criteria listed below for genetic testing. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Expedited fax: 888-235-8390. Effective 01/01/2023 (includes changes effective 04/01/2023) . Home Health/Home Infusion Therapy/Hospice: 888-567-5703. Most PDF readers are a free download. CareFirst Medicare Advantage requires notification/prior authorization of certain services. This step will help you determine if prior authorization may be required for a specific member and service. You'll also find news and updates for all lines of business. Independent licensees of the Blue Cross and Blue Shield Association. You'll also find news and updates for all lines of business. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. This tool is for outpatient services only. Inpatient Clinical: 800-416-9195. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Learn about the NAIC rules regarding coordination of benefits. Medical Clearance Forms and Certifications of Medical Necessity. 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.). A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. 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