External link You are leaving this website/app (site). endstream endobj 452 0 obj <. Start by choosing your patient's network listed below. We look forward to working with you to provide quality services to our members. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2022. Providers should call the prior authorization number on the back of the member ID card. From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. In Connecticut: Anthem Health Plans, Inc. Use of the Anthem websites constitutes your agreement with our Terms of Use. With three rich options to choose from, weve got you covered. For more information, please refer to the Medical Policy Reference Manual. 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. 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. PPO outpatient services do not require Pre-Service Review. Blue Cross and Blue Shield of Illinois, aDivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). For costs and complete details of the coverage, please contact your agent or the health plan. In addition, some sites may require you to agree to their terms of use and privacy policy. 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. 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. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Please use the To get started, select the state you live in. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 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. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. This approval process is called prior authorization. endstream endobj startxref CoverKids. 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. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. 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. Please refer to the criteria listed below for genetic testing. Some procedures may also receive instant approval. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Rx Prior Authorization. These manuals are your source for important information about our policies and procedures. Learn about the NAIC rules regarding coordination of benefits. Noncompliance with new requirements may result in denied claims. If you have any questions, call the number on the members ID card. These documents contain information about upcoming code edits. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. 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. Here you'll find information on the available plans and their benefits. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Type at least three letters and well start finding suggestions for you. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. Do not sell or share my personal information. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Prior Authorization Requirements. 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. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. BlueCross BlueShield of Tennessee uses a clinical editing database. Availity provides administrative services to BCBSIL. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. Prior authorization list. 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). AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. Independent licensees of the Blue Cross Association. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Independent licensees of the Blue Cross Association. Home Health/Home Infusion Therapy/Hospice: 888-567-5703. Future updates regarding COVID-19 will appear in the monthly Provider News publication. 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). 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. Mar 1, 2022 In Ohio: Community Insurance Company. 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 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. 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. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Select Auth/Referral Inquiry or Authorizations. CareFirst does not guarantee that this list is complete or current. BCBS FEP Vision covers frames, lenses, and eye exams. CareFirst Medicare Advantage requires notification/prior authorization of certain services. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. 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. Forms and information to help you request prior authorization or file an appeal. 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. 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. 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. 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. Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. In Maine: Anthem Health Plans of Maine, Inc. Or 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. This new site may be offered by a vendor or an independent third party. 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. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. Contact 866-773-2884 for authorization regarding treatment. Code pairs reported here are updated quarterly based on the following schedule. 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. Please verify benefit coverage prior to rendering services. 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. 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. Inpatient services and nonparticipating providers always require prior authorization. Information about benefits for your patients covered by the BlueCard program. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 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. 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 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. Contact 866-773-2884 for authorization regarding treatment. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. Forms and information about behavioral health services for your patients. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. In Kentucky: Anthem Health Plans of Kentucky, Inc. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. You can also check status of an existing request and auto-authorize more than 40 common procedures. Updated June 02, 2022. 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 Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. Third-Party Liability (TPL) Forms. Providers are responsible for verifying prior authorization requirements before services are rendered. %%EOF Independent licensees of the Blue Cross and Blue Shield Association. One option is Adobe Reader which has a built-in reader. Provider Enrollment Forms. 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. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. 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. Expedited fax: 888-235-8390. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. Prior Authorization. Not connected with or endorsed by the U.S. Government or the federal Medicare program. For your convenience, we've put these commonly used documents together in one place. Providers should continue to verify member eligibility and benefits prior to rendering services. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. CareFirst reserves the right to change this list at any time without notice. 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. Anthem offers great healthcare options for federal employees and their families. Enhanced Care Management (ECM) under CalAIM is a care management benefit that is community-based and provides a whole person approach to care that addresses the clinical and nonclinical needs of members with the most complex medical and social needs. 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. Bundling Rationale (Claims filed before Aug. 25, 2017). 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 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. 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. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Use of the Anthem websites constitutes your agreement with our Terms of Use. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Administrative. Medical Injectable Drugs: 833-581-1861. Effective 01/01/2023 (includes changes effective 04/01/2023) . Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. 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. In the event of an emergency, members may access emergency services 24/7. To get started, select the state you live in. You'll also find news and updates for all lines of business. Commercial Prior Authorization Summary and Code Lists The prior authorization information in this notice does not apply to requests for HMO members. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Electronic authorizations. 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 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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. 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. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. 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. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. Please Select Your State The resources on this page are specific to your state. 494 0 obj <>stream Medical Clearance Forms and Certifications of Medical Necessity. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. For your convenience, we've put these commonly used documents together in one place. 1 Cameron Hill Circle, Chattanooga TN 37402-0001, Change of Ownership and Provider ID Number Change Information. ). Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 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. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q In Ohio: Community Insurance Company. To view this file, you may need to install a PDF reader program. 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 U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. In Connecticut: Anthem Health Plans, Inc. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. 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