Medicare Advantage. endstream endobj 452 0 obj <. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Bundling Rationale (Claims filed before Aug. 25, 2017). 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Create your signature and click Ok. Press Done. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. endstream endobj startxref Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Medicaid Behavioral/Physical Health Coordination. 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 Choose My Signature. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). Most PDF readers are a free download. There are three variants; a typed, drawn or uploaded signature. 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. Not connected with or endorsed by the U.S. Government or the federal Medicare program. 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 Start by choosing your patient's network listed below. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. Details about new programs and changes to our procedures and guidelines. Expedited fax: 888-235-8390. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Prior authorization list. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. 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. Get the latest news to help improve your life and keep you healthy. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. 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. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. The purpose of this communication is the solicitation of insurance. Noncompliance with new requirements may result in denied claims. Look up common health coverage and medical terms. BlueCross BlueShield of Tennessee uses a clinical editing database. 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. We encourage providers to use CareFirst reserves the right to change this list at any time without notice. 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 Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. These documents contain information about upcoming code edits. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. 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. Inpatient Clinical: 800-416-9195. Updated June 02, 2022. Call our Customer Service number, (TTY: 711). * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. This approval process is called prior authorization. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. 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. Inpatient services and nonparticipating providers always require prior authorization. This list contains notification/prior authorization requirements for inpatient and outpatient services. Third-Party Liability (TPL) Forms. 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. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. We look forward to working with you to provide quality services to our members. These documents contain information about your benefits, network and coverage. %PDF-1.6 % Independent licensees of the Blue Cross and Blue Shield Association. Referencing the . eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. As your health needs evolve, our diverse plans are designed to evolve with you. In Connecticut: Anthem Health Plans, Inc. Please verify benefit coverage prior to rendering services. 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. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. In Indiana: Anthem Insurance Companies, Inc. It clarifies a utilization management vendor change for specific members. Anthem offers great healthcare options for federal employees and their families. If you have any questions, call the number on the members ID card. 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. Online - The AIM ProviderPortal is available 24x7. 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. For your convenience, we've put these commonly used documents together in one place. Fax medical prior authorization request forms to: 844-864-7853 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 verify benefit coverage prior to rendering services. Providers are responsible for verifying prior authorization requirements before services are rendered. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. Anthem offers great healthcare options for federal employees and their families. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. Please use the Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. 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. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. This step will help you determine if prior authorization may be required for a specific member and service. For your convenience, we've put these commonly used documents together in one place. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. Information about benefits for your patients covered by the BlueCard program. Type at least three letters and well start finding suggestions for you. 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. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. Or Musculoskeletal (eviCore): 800-540-2406. (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.). The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. 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. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Additionally, providers can use this tool to make inquiries on previously submitted requests, regardless of how they were sent (phone, fax, ICR or another online tool). 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. Providers should continue to verify member eligibility and benefits prior to rendering services. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. 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. 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. 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. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L Please check your schedule of benefits for coverage information. To get started, select the state you live in. Prior Authorization Requirements. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. Future updates regarding COVID-19 will appear in the monthly Provider News publication. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. Prior Authorization. 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. CareFirst does not guarantee that this list is complete or current. Select Auth/Referral Inquiry or Authorizations. Do not sell or share my personal information. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. CoverKids. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. 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. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. 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. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 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. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Some procedures may also receive instant approval. State & Federal / Medicare. 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 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. 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 To view this file, you may need to install a PDF reader program. PPO outpatient services do not require Pre-Service Review. 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 This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. Commercial. You can also refer to the provider manual for information about services that require prior authorization. This tool is for outpatient services only. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. %%EOF In the event of an emergency, members may access emergency services 24/7. 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. Nov 1, 2021 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. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 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. 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. 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. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. Code pairs reported here are updated quarterly based on the following schedule. Please refer to the criteria listed below for genetic testing. You can also check status of an existing request and auto-authorize more than 40 common procedures. You may also view the prior approval information in the Service Benefit Plan Brochures. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Scroll down to the table of contents. One option is Adobe Reader which has a built-in reader. The clinical editing rationale supporting this database is provided here to assist you in understanding the In Kentucky: Anthem Health Plans of Kentucky, 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. Anthem does not require prior authorization for treatment of emergency medical conditions. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. Select Patient Registration from the top navigation. 711. 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. Learn about the NAIC rules regarding coordination of benefits. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. Anthem is a registered trademark of Anthem Insurance Companies, Inc. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Administrative. 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. (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. 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. Independent licensees of the Blue Cross and Blue Shield Association. 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. Here youll find information on the available plans and their benefits. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. This approval process is called prior authorization. Providers should call the prior authorization number on the back of the member ID card. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. 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). 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