Prior Authorization Requirements. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans Forms and information about behavioral health services for your patients. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Please check your schedule of benefits for coverage information. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. Long-Term Care (LTC) Forms. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. Do not sell or share my personal information. Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Independent licensees of the Blue Cross Association. These documents contain information about your benefits, network and coverage. 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 hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q Forms and information about behavioral health services for your patients. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. Type at least three letters and well start finding suggestions for you. 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. You can also check status of an existing request and auto-authorize more than 40 common procedures. endstream endobj startxref Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists External link You are leaving this website/app (site). 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. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. Nov 1, 2021 To view this file, you may need to install a PDF reader program. Here you'll find information on the available plans and their benefits. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. Please use the 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. These manuals are your source for important information about our policies and procedures. You'll also find news and updates for all lines of business. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. 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 0 Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. 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. 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. Please refer to the criteria listed below for genetic testing. ). Please verify benefit coverage prior to rendering services. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. This tool is for outpatient services only. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. Information to help you maximize your performance in our quality programs. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. 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. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. 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. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. Serving Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. 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. Most PDF readers are a free download. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Please check your schedule of benefits for coverage information. Start by choosing your patient's network listed below. Large Group %%EOF Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. 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. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. rationale behind certain code pairs in the database. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Information about benefits for your patients covered by the BlueCard program. 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. 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. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. 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. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. 2022 Standard Pre-certification list . Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. Providers are responsible for verifying prior authorization requirements before services are rendered. 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. Third-Party Liability (TPL) Forms. Get the latest news to help improve your life and keep you healthy. Bundling Rationale (Claims filed before Aug. 25, 2017). eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Future updates regarding COVID-19 will appear in the monthly Provider News publication. Please verify benefit coverage prior to rendering services. 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. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. Contact 866-773-2884 for authorization regarding treatment. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) 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 With three rich options to choose from, weve got you covered. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. 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. Updated June 02, 2022. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). To get started, select the state you live in. %PDF-1.6 % (Note: For changes to come later this year, refer to this notice, posted Dec. 28, 2020: Commercial Prior Authorization Code Changes, Effective April 1, 2021. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. For costs and complete details of the coverage, please contact your agent or the health plan. 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 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 you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. In Ohio: Community Insurance Company. 494 0 obj <>stream 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 service for our members. Medicaid Behavioral/Physical Health Coordination. Please Select Your State The resources on this page are specific to your state. Prior authorization list. 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. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 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. Learn about the NAIC rules regarding coordination of benefits. Pharmacy Forms. 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. 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. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. For more information, please refer to the Medical Policy Reference Manual. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. 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. Administrative. 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. 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. 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