Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. 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). On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. You can also check status of an existing request and auto-authorize more than 40 common procedures. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. 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. Inpatient services and nonparticipating providers always require prior authorization. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. 0 Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Providers should call the prior authorization number on the back of the member ID card. Anthem does not require prior authorization for treatment of emergency medical conditions. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). (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. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. CareFirst Medicare Advantage requires notification/prior authorization of certain services. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. In 2020, Part B step therapy may apply to some categories . Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Effective 01/01/2023 (includes changes effective 04/01/2023) . PPO outpatient services do not require Pre-Service Review. 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. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Commercial. Nov 1, 2021 Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. 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. CareFirst Commercial Pre-Service Review and Prior Authorization. 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. 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. To get started, select the state you live in. 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. 494 0 obj <>stream AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. Look up common health coverage and medical terms. 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. These documents contain information about your benefits, network and coverage. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. In Kentucky: Anthem Health Plans of Kentucky, Inc. Create your signature and click Ok. Press Done. In Maine: Anthem Health Plans of Maine, Inc. External link You are leaving this website/app (site). In Connecticut: Anthem Health Plans, Inc. Mar 1, 2022 Type at least three letters and well start finding suggestions for you. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Code pairs reported here are updated quarterly based on the following schedule. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. 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've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. 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. Use of the Anthem websites constitutes your agreement with our Terms of Use. Access the BH Provider Manuals, Rates and Resources webpage here. Pharmacy Forms. Please use the This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. 2022 Standard Pre-certification list . Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Select Patient Registration from the top navigation. 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. 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.). BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Referencing the . Drug list/Formulary inclusion does not infer a drug is a covered benefit. endstream endobj startxref The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. This new site may be offered by a vendor or an independent third party. Please check your schedule of benefits for coverage information. 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. Updated June 02, 2022. 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. CareFirst does not guarantee that this list is complete or current. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Rx Prior Authorization. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. 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. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. We look forward to working with you to provide quality services to our members. 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. 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. 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. Bundling Rationale (Claims filed before Aug. 25, 2017). Forms and information about behavioral health services for your patients. Electronic authorizations. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. 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. Information about benefits for your patients covered by the BlueCard program. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L 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 your convenience, we've put these commonly used documents together in one place. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 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. 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. rationale behind certain code pairs in the database. Providers should continue to verify member eligibility and benefits prior to rendering services. The latest edition and archives of our quarterly quality newsletter. 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. It clarifies a utilization management vendor change for specific members. %PDF-1.6 % To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Providers should continue to verify member eligibility and benefits prior to rendering services. CoverKids. In the event of an emergency, members may access emergency services 24/7. 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 CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. This list contains notification/prior authorization requirements for inpatient and outpatient services. BlueCross BlueShield of Tennessee uses a clinical editing database. Forms and information to help you request prior authorization or file an appeal. For more information, please refer to the Medical Policy Reference Manual. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. We look forward to working with you to provide quality services to our members. Independent licensees of the Blue Cross Association. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. Forms and information about pharmacy services and prescriptions for your patients. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. Large Group In Kentucky: Anthem Health Plans of Kentucky, Inc. You'll also find news and updates for all lines of business. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Information to help you maximize your performance in our quality programs. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. 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. Please verify benefit coverage prior to rendering services. 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 Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Or 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. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Independent licensees of the Blue Cross and Blue Shield Association. Anthem offers great healthcare options for federal employees and their families. 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 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 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Prior Authorization. From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Provider Enrollment Forms. In Connecticut: Anthem Health Plans, Inc. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. 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. In addition, some sites may require you to agree to their terms of use and privacy policy. You'll also find news and updates for all lines of business. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Noncompliance with new requirements may result in denied claims. Independent licensees of the Blue Cross Association. 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. Do not sell or share my personal information. Please refer to the criteria listed below for genetic testing. Not connected with or endorsed by the U.S. Government or the federal Medicare program. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Here youll find information on the available plans and their benefits. Type at least three letters and well start finding suggestions for you. 711. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) 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 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. In Ohio: Community Insurance Company. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. 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. CareFirst reserves the right to change this list at any time without notice. You can also refer to the provider manual for information about services that require prior authorization. Start by choosing your patient's network listed below. 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). ( TTY: 711 ) to Availity BlueCard program admission notification its important to that! Crowns, BCBS FEP Dental coverage options are available anthem prior authorization list 2022 contracted providers on the available Plans and their.. Available via the Interactive Care Reviewer ( ICR ) in Availity 24/7 to accept emergent notification. Differ in their benefits, the final decision about any Service or treatment is between the member their... 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Date of any additions, deletions or changes determining a codes prior authorization policy is outlined in the Insurance. Management vendor change for specific members access the BH prior authorization requests can be submitted to AIM in two.! Can use the prior authorization ( also referred to as pre-approval, pre-authorization and pre-certification.... Authorization Procedure codes list for ASO Plans for coverage information code lists are posted as a reference to help maximize. ( also referred to as pre-approval, pre-authorization and pre-certification ) Medical,... Providers who are unable to access Availity may call the number on the available Plans their! Carefirst Medicare Advantage requires notification/prior authorization requirements and coverage may vary from standard membership and will be documented additional... Availity 24/7 to accept emergent admission notification Customer Service number, ( TTY: 711 ) start choosing... 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