Medical Clearance Forms and Certifications of Medical Necessity. In Indiana: Anthem Insurance Companies, Inc. In 2020, Part B step therapy may apply to some categories . 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 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. BlueCross BlueShield of Tennessee uses a clinical editing database. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. 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. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. 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. Nov 1, 2021 Anthem does not require prior authorization for treatment of emergency medical conditions. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 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. Please verify benefit coverage prior to rendering services. Please check your schedule of benefits for coverage information. 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. In addition, some sites may require you to agree to their terms of use and privacy policy. BCBS FEP Vision covers frames, lenses, and eye exams. Prior Authorization. From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. As your health needs evolve, our diverse plans are designed to evolve with you. 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. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Here you'll find information on the available plans and their benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. (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.). This approval process is called prior authorization. Start by choosing your patient's network listed below. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. 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. We look forward to working with you to provide quality service for our members. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Fax medical prior authorization request forms to: 844-864-7853 Large Group The latest edition and archives of our monthly provider newsletter. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. 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. Medicaid Behavioral/Physical Health Coordination. These documents contain information about your benefits, network and coverage. Select Patient Registration from the top navigation. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Not connected with or endorsed by the U.S. Government or the federal Medicare program. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Type at least three letters and well start finding suggestions for you. Providers should call the prior authorization number on the back of the member ID card. Select Auth/Referral Inquiry or Authorizations. Use of the Anthem websites constitutes your agreement with our Terms of Use. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. 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. Future updates regarding COVID-19 will appear in the monthly Provider News publication. 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. 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 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. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. For your convenience, we've put these commonly used documents together in one place. Please Select Your State The resources on this page are specific to your state. You can also check status of an existing request and auto-authorize more than 40 common procedures. Effective 01/01/2023 (includes changes effective 04/01/2023) . 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. 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. This step will help you determine if prior authorization may be required for a specific member and service. 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. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. 451 0 obj <> endobj Commercial Prior Authorization Summary and Code Lists With three rich options to choose from, weve got you covered. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). Information about benefits for your patients covered by the BlueCard program. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Some procedures may also receive instant approval. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Please refer to the criteria listed below for genetic testing. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. Inpatient Clinical: 800-416-9195. State & Federal / Medicare. Code pairs reported here are updated quarterly based on the following schedule. 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). 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. For costs and complete details of the coverage, please contact your agent or the health plan. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. 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). In Ohio: Community Insurance Company. In Connecticut: Anthem Health Plans, Inc. Look up common health coverage and medical terms. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q 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. It clarifies a utilization management vendor change for specific members. Learn about the NAIC rules regarding coordination of benefits. The clinical editing rationale supporting this database is provided here to assist you in understanding the Availity provides administrative services to BCBSIL. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. 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. 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. ). This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. 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. Medical Injectable Drugs: 833-581-1861. Prior authorization list. 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. Musculoskeletal (eviCore): 800-540-2406. 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've provided the following resources to help you understand Anthem's prior authorization process and obtain authorization for your patients when it's required. These documents contain information about upcoming code edits. This new site may be offered by a vendor or an independent third party. To view this file, you may need to install a PDF reader program. Anthem offers great healthcare options for federal employees and their families. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Scroll down to the table of contents. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CareFirst Commercial Pre-Service Review and Prior Authorization. Noncompliance with new requirements may result in denied claims. We encourage providers to use You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. 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 Contact will be made by an insurance agent or insurance company. 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. Inpatient services and nonparticipating providers always require prior authorization. For more information, please refer to the Medical Policy Reference Manual. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. External link You are leaving this website/app (site). Providers should continue to verify member eligibility and benefits prior to rendering services. CareFirst does not guarantee that this list is complete or current. Create your signature and click Ok. Press Done. In Kentucky: Anthem Health Plans of Kentucky, Inc. Forms and information to help you request prior authorization or file an appeal. 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. This tool is for outpatient services only. %%EOF Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. Administrative. If you have any questions, call the number on the members ID card. Choose My Signature. Long-Term Care (LTC) Forms. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. endstream endobj startxref You can also refer to the provider manual for information about services that require prior authorization. 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. Contact 866-773-2884 for authorization regarding treatment. 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. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 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. 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. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Use of the Anthem websites constitutes your agreement with our Terms of Use. 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. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . Referencing the . In Maine: Anthem Health Plans of Maine, Inc. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. 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. Rx Prior Authorization. The purpose of this communication is the solicitation of insurance. 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 Please refer to the criteria listed below for genetic testing. rationale behind certain code pairs in the database. Medicare Advantage. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). 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