anthem blue cross prior authorization list

Lastly, give the name of an office contact person along with the corresponding phone number, fax number, and email address. 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. 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. ), 0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed), 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure. . Portugus | L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, L3925 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf. They may request or review medical records, test results and other information so they understand what services are being performed and are able to make an informed decision. o Massachusetts Collaborative Prior Authorization Form or o Blue Cross Blue Shield of Massachusetts Pre-certification Request Form Click on the title for complete list of drugs that require prior authorization: Medical Benefit Prior Authorization Medication List, #034 Medical Utilization Management and Pharmacy Prior Authorization, #033 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. 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. Weve provided the following resources to help you understand Anthems prior authorization process and obtain authorization for your patients when its required. 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 Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. federal and Washington state civil rights laws. Healthcare Effectiveness Data and Information Set (HEDIS), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). View the FEP-specific code list and forms. Use the search tool to find the Care Center closest to you. URAC Accredited - Health Plan with Health Insurance Marketplace (HIM) - 7.3, URAC Accredited - Health Utilization Management - 7.4, Member forms - Individual and family plans, Coverage policy and pre-certification/pre-authorization, Approval information for radiological services, Medicare Advantage Prior Authorization Request Form, Part B Medication Prior Approval Request Form, Check deductible and out-of-pocket totals. Step 12 On page 2 (3), provide any details supporting the request (symptoms, clinic notes, lab results, etc.). Complete all member information fields on this form: Complete either the denial or the termination information section. Oct 1, 2020 View medication policies and pre-authorization requirements. The formcontains important information regarding the patients medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patients health care plan. We look forward to working with you to provide quality services to our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Your plan has a list of services that require prior authorization. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. You can also refer to the provider manual for information about services that require prior authorization. Anthem partners with health care professionals to close gaps in care and improve members overall heath. website. Some procedures may also receive instant approval. Independent licensees of the Blue Cross and Blue Shield Association. Secondly, it can be frustrating when a service not covered by your contract is performed by your doctor or specialist. Step 8 In Medication / Medical and Dispensing Information, indicate the administration method and administration location. TransactRx and CoverMyMeds are separate and independent companies that provide pharmacy pre-authorization and claims submission for Regence members. 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. Have you reviewed your online provider directory information lately? You can also visit bcbs.com to find resources for other states It looks like you're outside the United States. In Maine: Anthem Health Plans of Maine, Inc. If you have any questions regarding our Utilization Management or Prior Authorization process, please call Customer Service at the number on the back of your identification card and they can answer any general inquiries you may have. Select Auth/Referral Inquiry or Authorizations. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely. You understand and agree that by making any Step 7 In Medication / Medical and Dispensing Information, specify the following prescription details: dose/strength, frequency, length of therapy/number of refills, and quantity. Prior authorization requests are submitted on different websites for Individual and non-Individual plan members (groups, associations, etc.). Medical Policy and Prior Authorization for Blue Plans. As healthcare costs go up, health insurance premiums also go up to pay for the services provided. All rights reserved. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Submit a pharmacy pre-authorization through covermymeds.com or submit a claim with TransactRx. Step 10 On page 2 (1), select yes or no to indicate whether the patient has tried other medications for their condition. It looks like you're outside the United States. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Medicaid. To stay covered, Medicaid members will need to take action. 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. Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) has an online tool that displays prior authorization guidelines to help you quickly determine whether certain services for Anthem members require a prior authorization. or operation of any other website to which you may link from this website. Please refer to the criteria listed below for genetic testing. In Connecticut: Anthem Health Plans, Inc. | Espaol | Use of the Anthem websites constitutes your agreement with our Terms of Use. AIM Specialty Health will transition to Carelon Medical Benefits Management Inc. Anthem Blue Cross and Blue Shield will begin reimbursing for services provided by unlicensed clinical behavioral health providers actively seeking licensure in New Hampshire. March 2023 Anthem Provider News - New Hampshire, February 2023 Provider Newsletter - New Hampshire, Telephonic-only care allowance extended through April 11, 2023 - New Hampshire, January 2023 Provider Newsletter - New Hampshire, Reimbursement for services by clinical behavioral health providers seeking licensure, Time to prepare for HEDIS medical record review, New policy for EMR clinical data sharing and ADT notifications, Reimbursement policy update: Modifiers 25 and 57 - Professional, Specialty pharmacy updates for March 2023, Clinical Criteria updates for specialty pharmacy. of all such websites. We're here to work with you, your doctor and the facility so you have the best possible health outcome. Anthem has also made available a series of forms for specific medications which may provide more efficient service when making a request. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. View tools for submitting prior authorizationsfor Medicare Advantage members. The site may not work properly. 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. If we deny your request for coverage or you have questions regarding your prior authorization, please call Blue Cross of Idahos Customer Service. Independent licensees of the Blue Cross and Blue Shield Association. In Maine: Anthem Health Plans of Maine, Inc. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. You can find the number on the back of your ID card, or you can write to us at the following address: Appeals and Grievance CoordinatorBlue Cross of IdahoPO Box 7408Boise, ID 83707. Franais | We're encouraging our users to go ahead and switch to Microsoft Edge, Google Chrome, Safari or Firefox. Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements. Carelon Medical Benefits Management, Inc. You are invited: Advancing Mental Health Equity for Youth & Young Adults, Reminder: Updated Carelon Medical Benefits Management, Inc. Musculoskeletal Program effective April 1, 2023 - Site of care reviews, Carelon Medical Benefits Management (formerly AIM Specialty Health) Radiology Clinical Appropriateness Guidelines CPT code list update, Provider directory - annual audit for NCQA Accreditation, Statin Therapy Exclusions for Patients With Cardiovascular Disease/Diabetes HEDIS measures, March is National Colorectal Cancer Awareness Month, Reminder - Updated Carelon Musculoskeletal Program effective April 1, 2023: monitored anesthesia care reviews, Consumer payment option, Pay Doctor Bill, to terminate effective March 31, 2023, Pharmacy information available on our provider website, Controlling High Blood Pressure and Submitting Compliant Readings, Shared savings and transition care management after inpatient discharges. Prior authorization helps address the issue of rising healthcare costs by keeping procedures and services that are not medically necessary from being performed. We currently don't offer resources in your area, but you can select an option below to see information for that state. We currently don't offer resources in your area, but you can select an option below to see information for that state. under any circumstances for the activities, omissions or conduct of any owner or operator of any other We look forward to working with you to provide quality services to our members. 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 Ohio: Community Insurance Company. 2022 Electronic Forms LLC. Below that, write the name of the requester (if different than the prescriber) and supply the prescribers NPI number and DEA number. . Find care, claims & more with our new app. State & Federal / Medicare. may be offered to you through such other websites or by the owner or operator of such other websites. Please verify benefit coverage prior to rendering services. View requirements for group and Individual members on our commercial products. 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 Internet Explorer 11 browser application will be retired and go out of support on June 15, 2022. The Blue Cross name and symbol are registered marks of the Blue Cross Association. | Please refer to Availity Essentials portal, Arkansas Blue Cross Coverage Policy or the members In some cases, we require more information and will request additional records so we can make a fully informed decision. Prior Authorization details for providers outside of WA/AK. Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association and is licensed to offer health plans in all 75 counties of Arkansas. Out-of-area providers An Anthem(Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patients prescription cost. Prior Authorization Medication management With input from community physicians, specialty societies, and our Pharmacy & Therapeutics Committee, which includes community physicians and pharmacists from across the state, we design programs to help keep prescription drug coverage affordable. 2021 copyright of Anthem Insurance Companies, Inc. As a leader in managed healthcare services for the public sector, Anthem Blue Cross and Blue Shield Medicaid helps low-income families, children and pregnant women get the healthcare they need. Our electronic prior authorization (ePA) process is the preferred method for . The team reviews the requested service(s), determines if it is medically necessary and if the service is covered under your insurance plan. third-party website link available as an option to you, ABCBS does not in any way endorse any such website, If you're concerned about losing coverage, we can connect you to the right options for you and your family. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. 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. Learn more about electronic authorization. Anthem is a registered trademark of Anthem Insurance Companies, Inc. | Payments for services from a non-participating provider are generally sent to the member, except where federal or state mandates apply, or negotiated agreements are in place. This tool is for outpatient services only. Step 4 In Prescriber Information, specifythe prescribers full name, speciality, and full address. Medical and Behavioral Health Procedure Codes Requiring Prior Authorization: Providers please note that as of the 2/1/2022 Prior Authorization release, we are moving to one document that includes authorization requirements for Medical, Durable Medical Equipment, eviCore, and Behavioral Health rather than individual documents for each specialty. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Other Blue Plans pre-authorization requirements may differ from ours. No, the need for emergency services does not require prior authorization. However, if you receive services that are not medically necessary from a provider not contracting with Blue Cross of Idaho, you may be responsible for the entire cost of the services. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. ABCBS makes no warranties or representations of any kind, express or implied, nor We want you to receive the best care at the right time and place. others in any way for your decision to link to such other websites. affiliates, its directors, officers, employees and agents ("the ABCBS Parties") are not responsible for L3927 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (for example, static or ring type), may include soft interface material, prefabricated, L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system, L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee, L5645 Addition to lower extremity, below knee (BK), flexible inner socket, external frame, L5649 Addition to lower extremity, ischial containment/narrow M-L socket, L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each, 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed, 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure. website and are no longer accessing or using any ABCBS Data. 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. 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. Oromoo | Inpatient services and nonparticipating providers always require prior authorization. Denial of MH-TCM services is defined as the initial determination that a member does not meet the criteria for MH-TCM services. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. You are invited: Advancing Mental Health Equity for Youth & Young Adults. ), 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation, 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach, 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach, 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach, 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy), 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis, 33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure), 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed, 33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle, 33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only, 36514 Therapeutic Apheresis; Plasma Pheresis, 37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection, 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed, A4224 Supplies for maintenance of insulin infusion catheter, per week, A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each, A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe, A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fah, A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each, A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries, C1722 Cardioverter-defibrillator, single chamber (implantable), L5671 Addition to lower extremity, below knee (BK)/above knee (AK) suspension locking mechanism (shuttle, lanyard, or equal), excludes socket insert, L5673 Addition to lower extremity, below knee/above knee, custom fabricated, L5679 Addition to lower extremity, below knee/above knee, custom fabricated, L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature, L5981 All lower extremity prostheses, flex-walk system or equal, L5987 All lower extremity prostheses, shank foot system with vertical loading pylon, L8699 Prosthetic implant, not otherwise specified, L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code. Register today for the Advancing Mental Health Equity for Youth & Young Adults forum hosted by Anthem Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on March 15, 2023. FEP Basic Option/Standard OptionFEP Blue Focus. benefit certificate to determine which services need prior approval. In Indiana: Anthem Insurance Companies, Inc. If you receive services that are not medically necessary from one of Blue Cross of Idahos contracting providers without getting prior authorization and payment for the services is denied, you are not financially responsible. Anthem does not require prior authorization for treatment of emergency medical conditions. Contact CVS Caremark by phone at 844-345-3241 or visit their website. In Kentucky: Anthem Health Plans of Kentucky, Inc. View requirements for Basic Option, Standard Option and FEP Blue Focus. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Our resources vary by state. Call Provider Services at 1-800-450-8753 (TTY 711) After hours, verify member eligibility by calling the 24/7 NurseLine at 1-800-300-8181 To request authorizations: From the Availity home page, select Patient Registration from the top navigation. It is a pre-service determination of medical necessity based on information provided to Blue Cross of Idaho at the time the prior authorization request is made. We deliver personalized healthcare the way you want it, where you need it: in our neighborhood Care Centers, in your own home, in hospitals or skilled nursing facilities. In the case of a medical emergency, you do not need prior authorization to receive care.

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