You may also view the prior approval information in the Service Benefit Plan Brochures. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. Noncompliance with new requirements may result in denied claims. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. rationale behind certain code pairs in the database. Start by choosing your patient's network listed below. 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. We encourage providers to use 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. 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. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. The latest edition and archives of our quarterly quality newsletter. 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). 0 It clarifies a utilization management vendor change for specific members. Referencing the . 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. 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. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. As your health needs evolve, our diverse plans are designed to evolve with you. In Ohio: Community Insurance Company. 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. 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. Please verify benefit coverage prior to rendering services. This new site may be offered by a vendor or an independent third party. Contact 866-773-2884 for authorization regarding treatment. 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). Select Auth/Referral Inquiry or Authorizations. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. Here you'll find information on the available plans and their benefits. 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. Use of the Anthem websites constitutes your agreement with our Terms of Use. In addition, some sites may require you to agree to their terms of use and privacy policy. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. Third-Party Liability (TPL) Forms. 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.). 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 Providers should continue to verify member eligibility and benefits prior to rendering services. This approval process is called prior authorization. Prior authorization list. %PDF-1.6 % Musculoskeletal (eviCore): 800-540-2406. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). In Connecticut: Anthem Health Plans, Inc. 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 CoverKids. 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. CareFirst Commercial Pre-Service Review and Prior Authorization. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. 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. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . Large Group PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. ). In Indiana: Anthem Insurance Companies, Inc. Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. Inpatient services and nonparticipating providers always require prior authorization. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. 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. 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. In Maine: Anthem Health Plans of Maine, Inc. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. Contact 866-773-2884 for authorization regarding treatment. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. These manuals are your source for important information about our policies and procedures. 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. Medical Clearance Forms and Certifications of Medical Necessity. Inpatient Clinical: 800-416-9195. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) 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. The site may also contain non-Medicare related information. 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. BlueCross BlueShield of Tennessee uses a clinical editing database. 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. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. In Kentucky: Anthem Health Plans of Kentucky, Inc. Future updates regarding COVID-19 will appear in the monthly Provider News publication. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Pharmacy Forms. 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. Nov 1, 2021 For more information, please refer to the Medical Policy Reference Manual. Please refer to the criteria listed below for genetic testing. 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. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Use of the Anthem websites constitutes your agreement with our Terms of Use. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. We look forward to working with you to provide quality services to our members. 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. This approval process is called prior authorization. Anthem is a registered trademark of Anthem Insurance Companies, Inc. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. 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. 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. Updated June 02, 2022. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees 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. You'll also find news and updates for all lines of business. Select Patient Registration from the top navigation. Please verify benefit coverage prior to rendering services. Commercial. We look forward to working with you to provide quality service for our members. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. 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. To view this file, you may need to install a PDF reader program. 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. Create your signature and click Ok. Press Done. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. Information about benefits for your patients covered by the BlueCard program. The purpose of this communication is the solicitation of insurance. Scroll down to the table of contents. Do not sell or share my personal information. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. 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. Mar 1, 2022 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. For your convenience, we've put these commonly used documents together in one place. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. 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. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. Providers are responsible for verifying prior authorization requirements before services are rendered. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. 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. Do not sell or share my personal information. In 2020, Part B step therapy may apply to some categories . Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Providers should call the prior authorization number on the back of the member ID card. The clinical editing rationale supporting this database is provided here to assist you in understanding the The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. 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 2022 Standard Pre-certification list . 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