CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). CareFirst Commercial Pre-Service Review and Prior Authorization. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Do not sell or share my personal information. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. These documents contain information about upcoming code edits. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. You can also check status of an existing request and auto-authorize more than 40 common procedures. Contact will be made by an insurance agent or insurance company. Choose My Signature. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. Bundling Rationale (Claims filed before Aug. 25, 2017). BlueCross BlueShield of Tennessee uses a clinical editing database. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Forms and information to help you request prior authorization or file an appeal. In Ohio: Community Insurance Company. In Kentucky: Anthem Health Plans of Kentucky, Inc. ). Long-Term Care (LTC) Forms. endstream endobj startxref Details about new programs and changes to our procedures and guidelines. With three rich options to choose from, weve got you covered. 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 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. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Providers are responsible for verifying prior authorization requirements before services are rendered. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. You may also view the prior approval information in the Service Benefit Plan Brochures. 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 Referencing the . 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. 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. Start by choosing your patient's network listed below. Select Patient Registration from the top navigation. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Online - The AIM ProviderPortal is available 24x7. 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. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. 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. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. The purpose of this communication is the solicitation of insurance. 711. 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. For costs and complete details of the coverage, please contact your agent or the health plan. Blue Cross and Blue Shield of Illinois, aDivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). Please refer to the criteria listed below for genetic testing. Access the BH Provider Manuals, Rates and Resources webpage here. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 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. 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. 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. Commercial Prior Authorization Summary and Code Lists Anthem is a registered trademark of Anthem Insurance Companies, Inc. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Providers should call the prior authorization number on the back of the member ID card. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. These documents contain information about your benefits, network and coverage. For your convenience, we've put these commonly used documents together in one place. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. 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. %PDF-1.6 % Please use the Information to help you maximize your performance in our quality programs. 494 0 obj <>stream Pharmacy Forms. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Learn about the NAIC rules regarding coordination of benefits. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q Future updates regarding COVID-19 will appear in the monthly Provider News publication. This tool is for outpatient services only. Please check your schedule of benefits for coverage information. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. Please verify benefit coverage prior to rendering services. Look up common health coverage and medical terms. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. 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. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. Musculoskeletal (eviCore): 800-540-2406. In Ohio: Community Insurance Company. For your convenience, we've put these commonly used documents together in one place. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. Noncompliance with new requirements may result in denied claims. The clinical editing rationale supporting this database is provided here to assist you in understanding the Medical Injectable Drugs: 833-581-1861. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. Call our Customer Service number, (TTY: 711). 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 latest edition and archives of our monthly provider newsletter. 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. 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. This step will help you determine if prior authorization may be required for a specific member and service. 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.). One option is Adobe Reader which has a built-in reader. In Maine: Anthem Health Plans of Maine, Inc. Select Auth/Referral Inquiry or Authorizations. 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. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists In Connecticut: Anthem Health Plans, Inc. Forms and information about behavioral health services for your patients. It clarifies a utilization management vendor change for specific members. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Do not sell or share my personal information. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. 451 0 obj <> endobj CareFirst does not guarantee that this list is complete or current. 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. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. 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. 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. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross name and symbol are registered marks of the Blue Cross Association. PPO outpatient services do not require Pre-Service Review. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L Please verify benefit coverage prior to rendering services. Prior Authorization. BCBS FEP Vision covers frames, lenses, and eye exams. Independent licensees of the Blue Cross Association. Inpatient services and nonparticipating providers always require prior authorization. External link You are leaving this website/app (site). In addition, some sites may require you to agree to their terms of use and privacy policy. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. Availity provides administrative services to BCBSIL. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. Start by choosing your patient's network listed below. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Independent licensees of the Blue Cross and Blue Shield Association. (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. State & Federal / Medicare. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. We also support our providers with access to information about our plans and member benefits, news and updates, training materials and guides and other helpful resources. Expedited fax: 888-235-8390. As your health needs evolve, our diverse plans are designed to evolve with you. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Home Health/Home Infusion Therapy/Hospice: 888-567-5703. 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. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 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. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Please Select Your State The resources on this page are specific to your state. Nov 1, 2021 In Connecticut: Anthem Health Plans, Inc. 0 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. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. Prior authorization list. Contact 866-773-2884 for authorization regarding treatment. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan. 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). The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 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. 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. Here youll find information on the available plans and their benefits. In Kentucky: Anthem Health Plans of Kentucky, Inc. 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. 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.

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