2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. 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.). Noncompliance with new requirements may result in denied claims. Please verify benefit coverage prior to rendering services. Long-Term Care (LTC) Forms. (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.). As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) Contact will be made by an insurance agent or insurance company. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). 0 451 0 obj <> endobj Inpatient services and nonparticipating providers always require prior authorization. This approval process is called prior authorization. The latest edition and archives of our quarterly quality newsletter. 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. Independent licensees of the Blue Cross Association. 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. Most PDF readers are a free download. endstream endobj startxref Commercial. 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. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. With three rich options to choose from, weve got you covered. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. Musculoskeletal (eviCore): 800-540-2406. Not connected with or endorsed by the U.S. Government or the federal Medicare program. Please use the As your health needs evolve, our diverse plans are designed to evolve with you. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. Anthem offers great healthcare options for federal employees and their families. %PDF-1.6 % Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 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 requirements and coverage may vary from standard membership and will be documented in additional information sections. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Do not sell or share my personal information. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. 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. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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 view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. These documents contain information about your benefits, network and coverage. Medical Injectable Drugs: 833-581-1861. 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. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Please check your schedule of benefits for coverage information. ). In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. 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. Large Group ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. Referencing the . 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. 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). Forms and information to help you request prior authorization or file an appeal. 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. Forms and information about behavioral health services for your patients. Inpatient Clinical: 800-416-9195. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. Create your signature and click Ok. Press Done. Pharmacy Forms. State & Federal / Medicare. Scroll down to the table of contents. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. External link You are leaving this website/app (site). The prior authorization information in this notice does not apply to requests for HMO members. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. Online - The AIM ProviderPortal is available 24x7. Rx Prior Authorization. Here youll find information on the available plans and their benefits. CareFirst reserves the right to change this list at any time without notice. Please check your schedule of benefits for coverage information. Type at least three letters and well start finding suggestions for you. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In Ohio: Community Insurance Company. We look forward to working with you to provide quality services to our members. Anthem is a registered trademark of Anthem Insurance Companies, Inc. %%EOF Commercial Prior Authorization Summary and Code Lists CareFirst Medicare Advantage requires notification/prior authorization of certain services. Do not sell or share my personal information. . In Connecticut: Anthem Health Plans, Inc. You may also view the prior approval information in the Service Benefit Plan Brochures. 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. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. 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). In the event of an emergency, members may access emergency services 24/7. Code pairs reported here are updated quarterly based on the following schedule. 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. There are three variants; a typed, drawn or uploaded signature. Providers should continue to verify member eligibility and benefits prior to rendering services. 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. Start by choosing your patient's network listed below. To get started, select the state you live in. Contact 866-773-2884 for authorization regarding treatment. The latest edition and archives of our monthly provider newsletter. Please verify benefit coverage prior to rendering services. COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. Forms and information about behavioral health services for your patients. One option is Adobe Reader which has a built-in reader. 711. 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). In 2020, Part B step therapy may apply to some categories . 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. Please refer to the criteria listed below for genetic testing. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. Start by choosing your patient's network listed below. Medicaid Behavioral/Physical Health Coordination. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. 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. CoverKids. 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. The purpose of this communication is the solicitation of insurance. BlueCross BlueShield of Tennessee uses a clinical editing database. You'll also find news and updates for all lines of business. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. (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. Please refer to the criteria listed below for genetic testing. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. 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. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Administrative. Providers should call the prior authorization number on the back of the member ID card. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. 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. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. 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. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. BCBS FEP Vision covers frames, lenses, and eye exams. CareFirst does not guarantee that this list is complete or current. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. You'll also find news and updates for all lines of business. Information to help you maximize your performance in our quality programs. Prior authorization requirement changes effective June 1, 2022 Mar 1, 2022 State & Federal / Medicare On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. Updated June 02, 2022. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. 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 Anthem does not require prior authorization for treatment of emergency medical conditions. These documents contain information about upcoming code edits. From cleanings to crowns, BCBS FEP Dental coverage options are available for federal employees, retirees, and eligible retired uniformed service members. In Ohio: Community Insurance Company. This step will help you determine if prior authorization may be required for a specific member and service. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. 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. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. In Indiana: Anthem Insurance Companies, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. 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 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. We look forward to working with you to provide quality service for our members. The clinical editing rationale supporting this database is provided here to assist you in understanding the Bundling Rationale (Claims filed before Aug. 25, 2017). Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Prior authorization list. 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. 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. Medicare Advantage. In Maine: Anthem Health Plans of Maine, Inc. Select Auth/Referral Inquiry or Authorizations. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. Use of the Anthem websites constitutes your agreement with our Terms of Use. 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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