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. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Pharmacy Forms. 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 Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Drug list/Formulary inclusion does not infer a drug is a covered benefit. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. The 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). In 2020, Part B step therapy may apply to some categories . This step will help you determine if prior authorization may be required for a specific member and service. 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. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . rationale behind certain code pairs in the database. In Kentucky: Anthem Health Plans of Kentucky, Inc. Medicaid Behavioral/Physical Health Coordination. Use of the Anthem websites constitutes your agreement with our Terms of Use. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. 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. Details about new programs and changes to our procedures and guidelines. 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. Learn about the NAIC rules regarding coordination of benefits. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 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. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. 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. This approval process is called prior authorization. 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. Fax medical prior authorization request forms to: 844-864-7853 On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. 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 is a registered trademark of Anthem Insurance Companies, Inc. 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. The form contains important information regarding the patient's medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patient's health care plan. Inpatient services and nonparticipating providers always require prior authorization. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) Long-Term Care (LTC) Forms. 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. From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. Providers are responsible for verifying prior authorization requirements before services are rendered. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. Administrative. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. We encourage providers to use In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Inpatient services and nonparticipating providers always require prior authorization. One option is Adobe Reader which has a built-in reader. Information about benefits for your patients covered by the BlueCard program. Rx Prior Authorization. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. endstream endobj startxref Access the BH Provider Manuals, Rates and Resources webpage here. Contact 866-773-2884 for authorization regarding treatment. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. 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. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Expedited fax: 888-235-8390. CareFirst Commercial Pre-Service Review and Prior Authorization. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. The purpose of this communication is the solicitation of insurance. To get started, select the state you live in. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. endstream endobj 452 0 obj <. 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. Get the latest news to help improve your life and keep you healthy. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Please check your schedule of benefits for coverage information. This new site may be offered by a vendor or an independent third party. It clarifies a utilization management vendor change for specific members. As your health needs evolve, our diverse plans are designed to evolve with you. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). 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.). CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Anthem does not require prior authorization for treatment of emergency medical conditions. 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. 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. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists 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 You may also view the prior approval information in the Service Benefit Plan Brochures. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. We look forward to working with you to provide quality services to our members. Future updates regarding COVID-19 will appear in the monthly Provider News publication. Independent licensees of the Blue Cross Association. Provider Enrollment Forms. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. 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. Please check your schedule of benefits for coverage information. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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 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. Anthem offers great healthcare options for federal employees and their families. 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. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. In Ohio: Community Insurance Company. Please refer to the criteria listed below for genetic testing. Decide on what kind of signature to create. Here you'll find information on the available plans and their benefits. 451 0 obj <> endobj Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. CareFirst does not guarantee that this list is complete or current. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity.
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