Inpatient services and nonparticipating providers always require prior authorization. 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. Please check your schedule of benefits for coverage information. 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. 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. 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 Medical Clearance Forms and Certifications of Medical Necessity. Information about benefits for your patients covered by the BlueCard program. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. 844-912-0938 Email: OhioMedicaidProvider@anthem.com Prior authorization resources and contact information Services Requiring Prior Authorization Inpatient prior authorization fax numbers Physical health: 877-643-0671 Behavioral health: 866-577-2184 Medicaid prior authorization: 800-964-3627 Outpatient prior authorization fax numbers Rx Prior Authorization. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. endstream endobj startxref Independent licensees of the Blue Cross and Blue Shield Association. 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 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. Some procedures may also receive instant approval. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 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. 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. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 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. 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. Updated June 02, 2022. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. PPO outpatient services do not require Pre-Service Review. rationale behind certain code pairs in the database. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. 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. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). You'll also find news and updates for all lines of business. 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. State & Federal / Medicare. For more information, please refer to the Medical Policy Reference Manual. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. In Kentucky: Anthem Health Plans of Kentucky, Inc. Future updates regarding COVID-19 will appear in the monthly Provider News publication. Providers should continue to verify member eligibility and benefits prior to rendering services. Drug list/Formulary inclusion does not infer a drug is a covered benefit. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. 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. Look up common health coverage and medical terms. %%EOF Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. 451 0 obj <> endobj 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. 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. 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). Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. 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. The latest edition and archives of our quarterly quality newsletter. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. The site may also contain non-Medicare related information. 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. 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 Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. BCBS FEP Vision covers frames, lenses, and eye exams. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. 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. Start by choosing your patient's network listed below. ). Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. One option is Adobe Reader which has a built-in reader. CareFirst does not guarantee that this list is complete or current. You can also check status of an existing request and auto-authorize more than 40 common procedures. In 2020, Part B step therapy may apply to some categories . On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. Independent licensees of the Blue Cross Association. This step will help you determine if prior authorization may be required for a specific member and service. 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. Type at least three letters and well start finding suggestions for you. Administrative. 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. These documents contain information about your benefits, network and coverage. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. 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. Details about new programs and changes to our procedures and guidelines. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or 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. 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. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. 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 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. Please refer to the criteria listed below for genetic testing. For costs and complete details of the coverage, please contact your agent or the health plan. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q This approval process is called prior authorization. Expedited fax: 888-235-8390. 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. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Online - The AIM ProviderPortal is available 24x7. Inpatient services and nonparticipating providers always require prior authorization. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. To get started, select the state you live in. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Select Patient Registration from the top navigation. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. (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.). Prior authorization list. Choose My Signature. 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. 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. 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. Large Group We look forward to working with you to provide quality services to our members. Prior Authorization Requirements. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans 2022 Standard Pre-certification list . endstream endobj 452 0 obj <. 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. Providers should continue to verify member eligibility and benefits prior to rendering services. Use of the Anthem websites constitutes your agreement with our Terms of Use. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. 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 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 look forward to working with you to provide quality service for our members. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. In addition, some sites may require you to agree to their terms of use and privacy policy. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 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. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L For your convenience, we've put these commonly used documents together in one place. 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. External link You are leaving this website/app (site). In Kentucky: Anthem Health Plans of Kentucky, Inc. BlueCross BlueShield of Tennessee uses a clinical editing database. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Call our Customer Service number, (TTY: 711). Availity provides administrative services to BCBSIL. 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. Here you'll find information on the available plans and their benefits. CareFirst reserves the right to change this list at any time without notice. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. Home Health/Home Infusion Therapy/Hospice: 888-567-5703. 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. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. If you have any questions, call the number on the members ID card. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. You may also view the prior approval information in the Service Benefit Plan Brochures. Pharmacy Forms. These documents contain information about upcoming code edits. Medicare Advantage. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Code pairs reported here are updated quarterly based on the following schedule. CareFirst Medicare Advantage requires notification/prior authorization of certain services. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. Provider Enrollment Forms. Mar 1, 2022 BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. 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. Prior Authorization. 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. Commercial Prior Authorization Summary and Code Lists Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. This tool is for outpatient services only. Commercial. You'll also find news and updates for all lines of business. 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. For your convenience, we've put these commonly used documents together in one place. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. It clarifies a utilization management vendor change for specific members. 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. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. The prior authorization information in this notice does not apply to requests for HMO members. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. Access the BH Provider Manuals, Rates and Resources webpage here. Medicaid Behavioral/Physical Health Coordination. . This list contains notification/prior authorization requirements for inpatient and outpatient services. Providers should call the prior authorization number on the back of the member ID card. Please verify benefit coverage prior to rendering services. In Maine: Anthem Health Plans of Maine, Inc. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. 494 0 obj <>stream 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. Scroll down to the table of contents. In the event of an emergency, members may access emergency services 24/7. Forms and information about pharmacy services and prescriptions for your patients. Fax medical prior authorization request forms to: 844-864-7853 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. Please check your schedule of benefits for coverage information. Please verify benefit coverage prior to rendering services. 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