Select Auth/Referral Inquiry or Authorizations. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County.
Expedited fax: 888-235-8390. Third-Party Liability (TPL) Forms. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. In Maine: Anthem Health Plans of Maine, Inc. In Indiana: Anthem Insurance Companies, Inc. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. hbbd```b``+d3d]
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Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Providers should continue to verify member eligibility and benefits prior to rendering services. 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. Start by choosing your patient's network listed below. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. 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. To view this file, you may need to install a PDF reader program. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. 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. The Blue Cross name and symbol are registered marks of the Blue Cross Association. These manuals are your source for important information about our policies and procedures. 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. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. Decide on what kind of signature to create. Please verify benefit coverage prior to rendering services. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Forms and information about behavioral health services for your patients. Information to help you maximize your performance in our quality programs. Get the latest news to help improve your life and keep you healthy. This step will help you determine if prior authorization may be required for a specific member and service. 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. With three rich options to choose from, weve got you covered. Noncompliance with new requirements may result in denied claims. 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. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. CoverKids. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. 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. Musculoskeletal (eviCore): 800-540-2406. For costs and complete details of the coverage, please contact your agent or the health plan. Look up common health coverage and medical terms. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Commercial Prior Authorization Summary and Code Lists Some procedures may also receive instant approval. Long-Term Care (LTC) Forms. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans Please refer to the criteria listed below for genetic testing. There are three variants; a typed, drawn or uploaded signature. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. You can also refer to the provider manual for information about services that require prior authorization. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Contact 866-773-2884 for authorization regarding treatment. Inpatient services and nonparticipating providers always require prior authorization. Mar 1, 2022 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. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). These documents contain information about your benefits, network and coverage. endstream
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eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. You'll also find news and updates for all lines of business. ). Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. The clinical editing rationale supporting this database is provided here to assist you in understanding the Most PDF readers are a free download. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. Do not sell or share my personal information. Code pairs reported here are updated quarterly based on the following schedule. Prior Authorization Requirements. Forms and information about behavioral health services for your patients. 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. 494 0 obj
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ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Forms and information to help you request prior authorization or file an appeal. BlueCross BlueShield of Tennessee uses a clinical editing database. 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. This tool is for outpatient services only. To get started, select the state you live in. 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 list may vary based on account contracts and should be verified by contacting 1-866-773-2884. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 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. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. 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. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Scroll down to the table of contents. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 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. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. The latest edition and archives of our quarterly quality newsletter. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Community Supports under CalAIM are voluntary wrap-around services or settings available to members as a substitute for utilization of other services that focus on medical and/or needs that arise from social determinants of health. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Rx Prior Authorization. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 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. These documents contain information about upcoming code edits. 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. The prior authorization information in this notice does not apply to requests for HMO members. Here you'll find information on the available plans and their benefits. 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. 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. 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. Medicaid Behavioral/Physical Health Coordination. endstream
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Please use the Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. 0
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. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. Please Select Your State The resources on this page are specific to your state. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. CareFirst Commercial Pre-Service Review and Prior Authorization. In Ohio: Community Insurance Company. Updated June 02, 2022. We look forward to working with you to provide quality services to our members. 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. 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 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. 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 is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Here youll find information on the available plans and their benefits. 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. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. Effective 01/01/2023 (includes changes effective 04/01/2023) . Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Provider Enrollment Forms. Commercial. PPO outpatient services do not require Pre-Service Review. Electronic authorizations. Call our Customer Service number, (TTY: 711). For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Referencing the . 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 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. Choose My Signature. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. 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. Providers should call the prior authorization number on the back of the member ID card. 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. BCBS FEP Vision covers frames, lenses, and eye exams. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. 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. 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. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. 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. Providers should continue to verify member eligibility and benefits prior to rendering services. 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. State & Federal / Medicare. If you have any questions, call the number on the members ID card. %PDF-1.6
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2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. 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). Start by choosing your patient's network listed below. Large Group One option is Adobe Reader which has a built-in reader. Contact 866-773-2884 for authorization regarding treatment. 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 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 Please check your schedule of benefits for coverage information. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. 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). . This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. Prior Authorization. 711. 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 offers great healthcare options for federal employees and their families. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
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