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. This step will help you determine if prior authorization may be required for a specific member and service. We look forward to working with you to provide quality services to our members. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . Forms and information about pharmacy services and prescriptions for your patients. There are three variants; a typed, drawn or uploaded signature. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. 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. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). This new site may be offered by a vendor or an independent third party. We encourage providers to use 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. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. Electronic authorizations. From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. Do not sell or share my personal information. You can also check status of an existing request and auto-authorize more than 40 common procedures. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. Learn about the NAIC rules regarding coordination of benefits. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. 711. Select Auth/Referral Inquiry or Authorizations. Code pairs reported here are updated quarterly based on the following schedule. Look up common health coverage and medical terms. FEP Medications requiring online prior authorization, Intravenous Immune Globulin (IVIG) Therapy, Stereotactic Radiosurgery Using Gamma Rays, Surprise Billing - Out-Of-Network Provider Notice, Ambulance -elective air transport only (10.0.005), Behavioral Health and Substance Use Disorder (Milliman Care Guidelines), Repetitive Transcranial Magnetic Stimulation (TMS), Inpatient Behavioral Health and Substance Use Disorder, Home health care (Criteria defined in the employer group benefit contract), Home Infusion Therapy (Criteria defined in the employer group benefit contract), Hospice (Criteria defined in the employer group benefit contract), Inpatient rehabilitation (Apollo Managed Care Physical Therapy, Occupational Therapy and Rehabilitation Care), Maternity Services- inpatient only, for stay greater than 48/96 hours (Criteria defined in the employer group benefit contract), Out-of-network services (Benefits available according to the member contract), Private Duty Nursing (Criteria defined in the employer group benefit contract), Skilled nursing facility admissions (Apollo Managed Care Physical Therapy, Occupational Therapy and Rehabilitation Care). These manuals are your source for important information about our policies and procedures. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). The purpose of this communication is the solicitation of insurance. 477 0 obj <>/Filter/FlateDecode/ID[<530E5E682DBDAA468541E11BFAD96BAD>]/Index[451 44]/Info 450 0 R/Length 122/Prev 255106/Root 452 0 R/Size 495/Type/XRef/W[1 3 1]>>stream This tool is for outpatient services only. Referencing the . If you have any questions, call the number on the members ID card. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. 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. Scroll down to the table of contents. In Connecticut: Anthem Health Plans, Inc. 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. Anthem is a registered trademark of Anthem Insurance Companies, Inc. . Or 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. 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.). Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 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. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L Please Select Your State The resources on this page are specific to your state. rationale behind certain code pairs in the database. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q In Ohio: Community Insurance Company. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Choose My Signature. (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.). The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 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. 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. In 2020, Part B step therapy may apply to some categories . 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. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. Providers should call the prior authorization number on the back of the member ID card. Musculoskeletal (eviCore): 800-540-2406. Start by choosing your patient's network listed below. To get started, select the state you live in. Here youll find information on the available plans and their benefits. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. Details about new programs and changes to our procedures and guidelines. Inpatient services and nonparticipating providers always require prior authorization. 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 Maine: Anthem Health Plans of Maine, Inc. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. 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. Forms and information about behavioral health services for your patients. 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. These documents contain information about upcoming code edits. As your health needs evolve, our diverse plans are designed to evolve with you. 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. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Providers should continue to verify member eligibility and benefits prior to rendering services. To get started, select the state you live in. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. ). Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. For your convenience, we've put these commonly used documents together in one place. Pharmacy Forms. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. Information to help you maximize your performance in our quality programs. State & Federal / Medicare. 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 use the An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. The following summaries and related prior authorization lists were posted on the Support Materials (Government Programs) page as of Jan. 1, 2021: Important Reminder: Check Eligibility and Benefits First BlueCross BlueShield of Tennessee uses a clinical editing database. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. %PDF-1.6 % 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. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Information about benefits for your patients covered by the BlueCard program. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. You'll also find news and updates for all lines of business. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. 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. For your convenience, we've put these commonly used documents together in one place. 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. Please refer to the criteria listed below for genetic testing. Access eligibility and benefits information on the Availity Web Portal or Use the Prior Authorization Lookup Tool within Availity or Contact the Customer Care Center: Outside Los Angeles County: 1-800-407-4627 Inside Los Angeles County: 1-888-285-7801 Customer Care Center hours are Monday to Friday 7 a.m. to 7 p.m. Fax medical prior authorization request forms to: 844-864-7853 The clinical editing rationale supporting this database is provided here to assist you in understanding the ICR offers a fast, efficient way to securely submit your requests with clinical documentation. Most PDF readers are a free download. Inpatient Clinical: 800-416-9195. 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. Independent licensees of the Blue Cross and Blue Shield Association. For costs and complete details of the coverage, please contact your agent or the health plan. Please verify benefit coverage prior to rendering services. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans Prior Authorization. Get the latest news to help improve your life and keep you healthy. The latest edition and archives of our monthly provider newsletter. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . 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. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. Use of the Anthem websites constitutes your agreement with our Terms of Use. In Maine: Anthem Health Plans of Maine, Inc. 494 0 obj <>stream 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. Select Patient Registration from the top navigation. 0 Use of the Anthem websites constitutes your agreement with our Terms of Use. AIM Specialty Health (AIM) is an operating subsidiary of Anthem, Inc., an independent specialty medical benefits management company that provides utilization management services for BCBSTX. Medical Clearance Forms and Certifications of Medical Necessity. 2022 Standard Pre-certification list . The latest edition and archives of our quarterly quality newsletter. Rx Prior Authorization. PPO outpatient services do not require Pre-Service Review. Type at least three letters and well start finding suggestions for you. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. The prior authorization information in this notice does not apply to requests for HMO members. Type at least three letters and well start finding suggestions for you. It clarifies a utilization management vendor change for specific 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. 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. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 451 0 obj <> endobj You may also view the prior approval information in the Service Benefit Plan Brochures. Providers are responsible for verifying prior authorization requirements before services are rendered. Expedited fax: 888-235-8390. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In addition, some sites may require you to agree to their terms of use and privacy policy. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. CareFirst Commercial Pre-Service Review and Prior Authorization. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. 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. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. 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. endstream endobj startxref For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. External link You are leaving this website/app (site). Contact 866-773-2884 for authorization regarding treatment. Updated June 02, 2022. In Kentucky: Anthem Health Plans of Kentucky, Inc. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. 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. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. Drug list/Formulary inclusion does not infer a drug is a covered benefit. In Ohio: Community Insurance Company. Anthem does not require prior authorization for treatment of emergency medical conditions. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. 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 Not connected with or endorsed by the U.S. Government or the federal Medicare program. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. %%EOF Noncompliance with new requirements may result in denied claims. 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. In Indiana: Anthem Insurance Companies, Inc. 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. 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. Independent licensees of the Blue Cross Association. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. 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. Medicare Advantage. Some procedures may also receive instant approval. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. 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. With three rich options to choose from, weve got you covered. CareFirst reserves the right to change this list at any time without notice. Independent licensees of the Blue Cross and Blue Shield Association. PPO outpatient services do not require Pre-Service Review. 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. 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