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. We look forward to working with you to provide quality services to our members. Independent licensees of the Blue Cross and Blue Shield Association. Use of the Anthem websites constitutes your agreement with our Terms of Use. 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. 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. In 2020, Part B step therapy may apply to some categories . Providers are responsible for verifying prior authorization requirements before services are rendered. 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. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. Drug list/Formulary inclusion does not infer a drug is a covered benefit. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. 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). CoverKids. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. Look up common health coverage and medical terms. Medicaid Behavioral/Physical Health Coordination. Noncompliance with new requirements may result in denied claims. 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. 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. %%EOF Musculoskeletal (eviCore): 800-540-2406. 0 eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. 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. 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. This tool is for outpatient services only. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. Future updates regarding COVID-19 will appear in the monthly Provider News publication. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) Contact 866-773-2884 for authorization regarding treatment. 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 and Blue Shield Association. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. Create your signature and click Ok. Press Done. State & Federal / Medicare. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). This new site may be offered by a vendor or an independent third party. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. 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. Medical Clearance Forms and Certifications of Medical Necessity. Inpatient services and nonparticipating providers always require prior authorization. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans 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. Call our Customer Service number, (TTY: 711). 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. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). 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'll also find news and updates for all lines of business. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. PPO outpatient services do not require Pre-Service Review. 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. Third-Party Liability (TPL) Forms. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. With three rich options to choose from, weve got you covered. 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 is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 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 Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. 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. 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 step will help you determine if prior authorization may be required for a specific member and service. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. You can also refer to the provider manual for information about services that require prior authorization. In Kentucky: Anthem Health Plans of Kentucky, 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. Administrative. 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. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. You can also check status of an existing request and auto-authorize more than 40 common procedures. External link You are leaving this website/app (site). Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. Updated June 02, 2022. Drug list/Formulary inclusion does not infer a drug is a covered benefit. The clinical editing rationale supporting this database is provided here to assist you in understanding the To get started, select the state you live in. (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.). Please check your schedule of benefits for coverage information. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. 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. Type at least three letters and well start finding suggestions for you. Commercial. Electronic authorizations. 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. For more information, please refer to the Medical Policy Reference Manual. This approval process is called prior authorization. In the event of an emergency, members may access emergency services 24/7. 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 call the prior authorization number on the back of the member ID card. Information to help you maximize your performance in our quality programs. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L 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.). 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. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. 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. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In Ohio: Community Insurance Company. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. As your health needs evolve, our diverse plans are designed to evolve with you. Decide on what kind of signature to create. CareFirst Commercial Pre-Service Review and Prior Authorization. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. The site may also contain non-Medicare related information. Availity provides administrative services to BCBSIL. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. CareFirst Medicare Advantage requires notification/prior authorization of certain services. (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. endstream endobj startxref Large Group * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. 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. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. Not connected with or endorsed by the U.S. Government or the federal Medicare program. Scroll down to the table of contents. We look forward to working with you to provide quality services to our members. Prior authorization list. In Maine: Anthem Health Plans of Maine, Inc. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. 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