2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. We look forward to working with you to provide quality service for our members. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 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. 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 Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. 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. 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. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. 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). Effective 01/01/2023 (includes changes effective 04/01/2023) . 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. For your convenience, we've put these commonly used documents together in one place. 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. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Nov 1, 2021 As your health needs evolve, our diverse plans are designed to evolve with you. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Contact will be made by an insurance agent or insurance company. 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 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. Some procedures may also receive instant approval. 494 0 obj <>stream Commercial Prior Authorization Summary and Code Lists Please use the Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. Get the latest news to help improve your life and keep you healthy. . 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. CareFirst Medicare Advantage requires notification/prior authorization of certain services. Anthem offers great healthcare options for federal employees and their families. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. 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. Start by choosing your patient's network listed below. %%EOF 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. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. The prior authorization information in this notice does not apply to requests for HMO members. Select Auth/Referral Inquiry or Authorizations. In Indiana: Anthem Insurance Companies, Inc. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) BlueCross BlueShield of Tennessee uses a clinical editing database. Anthem offers great healthcare options for federal employees and their families. 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. We look forward to working with you to provide quality services to our members. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. Here you'll find information on the available plans and their benefits. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. Musculoskeletal (eviCore): 800-540-2406. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans Large Group 2005 - 2022 copyright of Anthem Insurance Companies, Inc. Forms and information about behavioral health services for your patients. 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. rationale behind certain code pairs in the database. Learn about the NAIC rules regarding coordination of benefits. endstream endobj startxref %PDF-1.6 % Third-Party Liability (TPL) Forms. In the event of an emergency, members may access emergency services 24/7. One option is Adobe Reader which has a built-in reader. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. The latest edition and archives of our monthly provider newsletter. Independent licensees of the Blue Cross and Blue Shield Association. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. 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. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). 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. Please refer to the criteria listed below for genetic testing. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. In Connecticut: Anthem Health Plans, Inc. Noncompliance with new requirements may result in denied claims. In Maine: Anthem Health Plans of Maine, Inc. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. 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. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L This approval process is called prior authorization. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. The site may also contain non-Medicare related information. Inpatient services and nonparticipating providers always require prior authorization. Please check your schedule of benefits for coverage information. This approval process is called 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. PPO outpatient services do not require Pre-Service Review. Call our Customer Service number, (TTY: 711). The Blue Cross name and symbol are registered marks of the Blue Cross Association. Details about new programs and changes to our procedures and guidelines. 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. 711. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. Administrative. 0 CareFirst does not guarantee that this list is complete or current. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. PPO outpatient services do not require Pre-Service Review. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. 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. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. BCBS FEP Vision covers frames, lenses, and eye exams. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Drug list/Formulary inclusion does not infer a drug is a covered benefit. In Kentucky: Anthem Health Plans of Kentucky, Inc. 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. Medical Injectable Drugs: 833-581-1861. 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. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. 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. 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. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. Independent licensees of the Blue Cross Association. Updated June 02, 2022. Type at least three letters and well start finding suggestions for you. Anthem is a registered trademark of Anthem Insurance Companies, Inc. In addition, some sites may require you to agree to their terms of use and privacy policy. Future updates regarding COVID-19 will appear in the monthly Provider News publication. 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 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. 451 0 obj <> endobj 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 Please refer to the criteria listed below for genetic testing. State & Federal / Medicare. Information about benefits for your patients covered by the BlueCard program. 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. 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. We look forward to working with you to provide quality services to our members. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. To view this file, you may need to install a PDF reader program. 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). You'll also find news and updates for all lines of business. 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. 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. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. Please verify benefit coverage prior to rendering services. 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. Prior Authorization Requirements. Medical Clearance Forms and Certifications of Medical Necessity. 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. 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. For costs and complete details of the coverage, please contact your agent or the health plan. Pharmacy Forms. 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. Independent licensees of the Blue Cross Association. Anthem does not require prior authorization for treatment of emergency medical conditions. Choose My Signature. 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. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. 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 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.). 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. Providers should call the prior authorization number on the back of the member ID card. CareFirst Commercial Pre-Service Review and Prior Authorization. Rx Prior Authorization. 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. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. The purpose of this communication is the solicitation of insurance. 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. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. 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. Commercial. 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. Long-Term Care (LTC) Forms. Providers are responsible for verifying prior authorization requirements before services are rendered. 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. ). In Ohio: Community Insurance Company. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . Do not sell or share my personal information. These documents contain information about your benefits, network and coverage. Scroll down to the table of contents. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Code pairs reported here are updated quarterly based on the following schedule. Electronic authorizations. National Accounts, Posts about using health Insurance and managing your health, Collections of learning resources and links to services, For Sydney Health users connect with others and find care programs. Use of the Anthem websites constitutes your agreement with our Terms of Use. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Here youll find information on the available plans and their benefits. Bundling Rationale (Claims filed before Aug. 25, 2017). You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. Online - The AIM ProviderPortal is available 24x7. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. The Blue Cross name and symbol are registered marks of the Blue Cross Association. You can also check status of an existing request and auto-authorize more than 40 common procedures. 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. 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. 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 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 Kentucky: Anthem Health Plans of Kentucky, Inc. Please Select Your State The resources on this page are specific to your state. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. 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