anthem blue cross prior authorization list

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. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. Do you offer telehealth services? Please refer to Availity Essentials portal, Arkansas Blue Cross Coverage Policy or the members The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Independent licensees of the Blue Cross and Blue Shield Association. However, if you receive services that are not medically necessary from a provider not contracting with Blue Cross of Idaho, you may be responsible for the entire cost of the services. The Internet Explorer 11 browser application will be retired and go out of support on June 15, 2022. View requirements for Basic Option, Standard Option and FEP Blue Focus. 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. Your dashboard may experience future loading problems if not resolved. website and are no longer accessing or using any ABCBS Data. In Kentucky: Anthem Health Plans of Kentucky, Inc. benefit certificate to determine which services need prior approval. View tools for submitting prior authorizationsfor Medicare Advantage members. In the case of a medical emergency, you do not need prior authorization to receive care. Step 2 In Patient Information, provide the patients full name, phone number, full address, date of birth, sex (m/f), height, and weight. Step 11 On page 2 (2), list all diagnoses and provide theICD-9/ICD-10. FEP utilizes Magellan Rx Management for medical, Providers requesting prior approval for an ASE/PSE member should use the appropriate form on the, Providers who are requesting a prior approval for Walmart or other BlueAdvantage members should use the appropriate form from the, Providers who are requesting a prior approval for BlueMedicare or Health Advantage Medicare Advantage members should use the appropriate form from, Providers requesting prior approval for Part B drugs for BlueMedicare or Health Advantage Medicare should use the, Name and telephone number of contact person, Requesting / Performing Providers NPI or Provider ID, Copy of members insurance card (front/back), CPT Code(s), ICD 10/HCPCS Code(s), Modifiers that are applicable, Please use the most descriptive procedure and diagnosis codes, Medical records to support requested services. February 2023 Anthem Provider News - Ohio, New ID cards for Anthem Blue Cross and Blue Shield members - Ohio, Telephonic-only care allowance extended through April 11, 2023 - Ohio, C1764 Event recorder, cardiac (implantable), E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized, E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment, L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each, L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each, L3310 Lift, elevation, heel and sole, neoprene, per inch, L3332 Lift, elevation, inside shoe, tapered, up to one-half inch, L3580 Ortho shoe add instep Velcro closure, L3610 Transfer of an orthosis from one shoe to another, caliper plate, new, L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing, L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new, L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified, L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf, L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf, L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf, L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf, L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise, L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type, L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf, L3913 HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment, L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. 2021 copyright of Anthem Insurance Companies, Inc. As a leader in managed healthcare services for the public sector, Anthem Blue Cross and Blue Shield Medicaid helps low-income families, children and pregnant women get the healthcare they need. Blueprint Portal is a members-only website that will help you understand and manage your health plan so youre able to find quality, patient-focused healthcare at the best possible price. In the event of an emergency, members may access emergency services 24/7. It is a pre-service determination of medical necessity based on information provided to Blue Cross of Idaho at the time the prior authorization request is made. Use these lists to identify the member services that require prior authorization. Electronic authorizations. We currently don't offer resources in your area, but you can select an option below to see information for that state. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at availity.com at anthem.com/medicareprovider > Login. Anthem has also made available a series of forms for specific medications which may provide more efficient service when making a request. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. 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., 2023. | ABCBS makes no warranties or representations of any kind, express or implied, nor Noncompliance with new requirements may result in denied claims. Our resources vary by state. Complete all member information fields on this form: Complete either the denial or the termination information section. 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. Anthem is a registered trademark of Anthem Insurance Companies, Inc. or operation of any other website to which you may link from this website. Anthem is a registered trademark of Anthem Insurance Companies, Inc. | We're here to work with you, your doctor and the facility so you have the best possible health outcome. This tool does not reflect benefits coverage, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity. URAC Accredited - Health Plan with Health Insurance Marketplace (HIM) - 7.3, URAC Accredited - Health Utilization Management - 7.4, Member forms - Individual and family plans, Coverage policy and pre-certification/pre-authorization, Approval information for radiological services, Medicare Advantage Prior Authorization Request Form, Part B Medication Prior Approval Request Form, Check deductible and out-of-pocket totals. Carelon Medical Benefits Management, Inc. You are invited: Advancing Mental Health Equity for Youth & Young Adults, Reminder: Updated Carelon Medical Benefits Management, Inc. Musculoskeletal Program effective April 1, 2023 - Site of care reviews, Carelon Medical Benefits Management (formerly AIM Specialty Health) Radiology Clinical Appropriateness Guidelines CPT code list update, Provider directory - annual audit for NCQA Accreditation, Statin Therapy Exclusions for Patients With Cardiovascular Disease/Diabetes HEDIS measures, March is National Colorectal Cancer Awareness Month, Reminder - Updated Carelon Musculoskeletal Program effective April 1, 2023: monitored anesthesia care reviews, Consumer payment option, Pay Doctor Bill, to terminate effective March 31, 2023, Pharmacy information available on our provider website, Controlling High Blood Pressure and Submitting Compliant Readings, Shared savings and transition care management after inpatient discharges. This may result in a delay of our determination response. Some procedures may also receive instant approval. affiliates, its directors, officers, employees and agents ("the ABCBS Parties") are not responsible for Sep 1, 2021 Important: Blueprint Portal will not load if you are using Internet Explorer. With convenience in mind, Care Centers are at the heart of the patient health journey. Do not sell or share my personal information. InteractiveCare Reviewer is a utilization management tool that lets you submit prior authorization requests and other clinical information quickly and easily. Contact CVS Caremark by phone at 844-345-3241 or visit their website. 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. 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. You are invited: Advancing Mental Health Equity for Youth & Young Adults. We want you to receive the best care at the right time and place. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Prior authorization is not a guarantee of payment. It looks like you're outside the United States. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Medicaid. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at availity.com at anthem.com/medicareprovider > Login. Step 13 The prescriber must provide their signature at the bottom of the form and the date of signing. of all such websites. Prior Authorization Medication management With input from community physicians, specialty societies, and our Pharmacy & Therapeutics Committee, which includes community physicians and pharmacists from across the state, we design programs to help keep prescription drug coverage affordable. Find a Care Center. 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 does not require prior authorization for treatment of emergency medical conditions. of merchantability or fitness for a particular purpose, nor of non-infringement, with regard to the content In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Please note that CarelonRx is the pharmacy benefits manager for Medicare Advantage plans. March 2023 Anthem Provider News - Georgia, February 2023 Anthem Provider News - Georgia, New ID cards for Anthem Blue Cross and Blue Shield members - Georgia, Telephonic-only care allowance extended through April 11, 2023 - Georgia, January 2023 Anthem Provider News - Georgia, prior authorization/precertification form, September 2021 Anthem Provider News - Georgia. Please verify benefit coverage prior to rendering services. An Independent Licensee of the Blue Cross and Blue Shield Association, Summary of Benefits & Coverage Information, Sleep Testing and Therapy & Advanced Imaging, Confirm your specific treatment plan and medical necessity given your diagnosis, Determine if services are eligible for coverage, Assure your claims are processed accurately and timely, Save you from unnecessary medical expenses. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. In Indiana: Anthem Insurance Companies, Inc. The formcontains important information regarding the patients medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patients health care plan. 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. Your contract lists covered services, like a wellness exam, immunization or a diagnostic test. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. Your plan has a list of services that require prior authorization. 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 update your browser if the service fails to run our website. Step 10 On page 2 (1), select yes or no to indicate whether the patient has tried other medications for their condition. Polski | The CarelonRx member services telephone number is 833-279-0458. 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. March 2023 Anthem Provider News - New Hampshire, February 2023 Provider Newsletter - New Hampshire, Telephonic-only care allowance extended through April 11, 2023 - New Hampshire, January 2023 Provider Newsletter - New Hampshire, Reimbursement for services by clinical behavioral health providers seeking licensure, Time to prepare for HEDIS medical record review, New policy for EMR clinical data sharing and ADT notifications, Reimbursement policy update: Modifiers 25 and 57 - Professional, Specialty pharmacy updates for March 2023, Clinical Criteria updates for specialty pharmacy. | Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., independent licensee of the Blue Cross and Blue Shield Association. 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. No, the need for emergency services does not require prior authorization. In Ohio: Community Insurance Company. Prior approval for requested services - Arkansas Blue Cross and Blue Shield Prior approval for requested services The primary coverage criteria of certain services must be established through a prior Approval or pre-authorization process before they can be performed. If you're concerned about losing coverage, we can connect you to the right options for you and your family. If we deny your request for coverage or you have questions regarding your prior authorization, please call Blue Cross of Idahos Customer Service. CareMore Health is a leading primary care provider that specializes in chronic and complex conditions. With prior authorization, Blue Cross of Idaho is able to: Prior authorization is just one of the ways we're working to save our members money and address rising healthcare costs. The primary coverage criteria of certain services must be established through a prior Approval or pre-authorization process before they can be performed. This form should only be used for Arkansas Blue Cross and Blue Shield members. nor state or imply that you should access such website or any services, products or information which 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. Use of the Anthem websites constitutes your agreement with our Terms of Use. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. You can access the Precertification Lookup Tool through the Availity Portal. PPO outpatient services do not require Pre-Service Review. Select Auth/Referral Inquiry or Authorizations. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital . View medication policies and pre-authorization requirements. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. To learn more read Microsoft's help article. If your state isn't listed, check out bcbs.com to find coverage in your area. In Connecticut: Anthem Health Plans, Inc. Let us know! It looks like you're in . You understand and agree that by making any You can also visit bcbs.com to find resources for other states It looks like you're outside the United States. Federal Employee Program. 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. Healthcare Effectiveness Data and Information Set (HEDIS), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Prior authorization requests are submitted on different websites for Individual and non-Individual plan members (groups, associations, etc.). If yes, provide the medication name, dosage, duration of therapy, and outcome. Out-of-area providers ), 0480T Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure. Prior Authorization details for providers outside of WA/AK. Submit a pharmacy pre-authorization through covermymeds.com or submit a claim with TransactRx. Fax the completed form to 1-844-429-7757 within one business day of the determination/action. 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 resources for our providers may differ between states. FEP Basic Option/Standard OptionFEP Blue Focus. Typically, we complete this review within two business days, and notify you and your provider of our decision. | Inpatient services and nonparticipating providers always require prior authorization. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). under any circumstances for the activities, omissions or conduct of any owner or operator of any other Our electronic prior authorization (ePA) process is the preferred method for . Use of the Anthem websites constitutes your agreement with our Terms of Use. We currently don't offer resources in your area, but you can select an option below to see information for that state. o Massachusetts Collaborative Prior Authorization Form or o Blue Cross Blue Shield of Massachusetts Pre-certification Request Form Click on the title for complete list of drugs that require prior authorization: Medical Benefit Prior Authorization Medication List, #034 Medical Utilization Management and Pharmacy Prior Authorization, #033 Blue Cross of Idaho retains the right to review the medical necessity of services, eligibility for services and benefit limitations and exclusions after you receive the services. Copyright 2001-2023 Arkansas Blue Cross and Blue Shield. Please note that CVS Caremark administers the pharmacy benefits for the State Health Benefit Plan. Also, specify any allergies and give the name and phone number of the patients authorized representative (if applicable). Below that, write the name of the requester (if different than the prescriber) and supply the prescribers NPI number and DEA number. 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. The owners or operators of any other websites (not ABCBS) are solely responsible for the content and operation To stay covered, Medicaid members will need to take action. The site may not work properly. 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. Information about COVID-19 and your insurance coverage. Online - The AIM ProviderPortal is available 24x7. There is a list of these services in your member contract. 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. Located in neighborhoods all over the country, CareMore Health Care Centers combine a variety of different specialty services under one roof. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Sign in to the appropriate website to complete your request. Inpatient services and nonparticipating providers always require prior authorization. Weve provided the following resources to help you understand Anthems prior authorization process and obtain authorization for your patients when its required. 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. Administrative. 1 Services may be listed as requiring prior authorization that may not be covered benefits for a particular member. Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements. By using the website, you agree to our use of cookies to analyze website traffic and improve your experience on our website. Prior authorization is required for surgical services only. If you choose to access other websites from this website, you agree, as a condition of choosing any such 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. Espaol | In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Independent licensees of the Blue Cross and Blue Shield Association. 2023 Regence health plans are Independent Licensees of the Blue Cross and Blue Shield Association serving members in Idaho, Oregon, Utah and select counties of Washington. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely. Independent licensees of the Blue Cross Association. Therefore, its important for you to know your benefits and covered services. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. If you have any questions regarding our Utilization Management or Prior Authorization process, please call Customer Service at the number on the back of your identification card and they can answer any general inquiries you may have. Italiano | | In Kentucky: Anthem Health Plans of Kentucky, Inc. Kreyl Ayisyen | may be offered to you through such other websites or by the owner or operator of such other websites. Type at least three letters and we will start finding suggestions for you. Prior to surgical treatment of gender dysphoria in FEP members, you must submit a treatment plan, including all surgeries planned, and the estimated date each will be performed. For both outpatient procedures and treatment requiring an inpatient stay, call (800) 633-4581 to obtain prior authorization. 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 look forward to working with you to provide quality services to our members. Contracted and non-contracted providers who are unable to access Availity* may call the number on the back of the members ID card. 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 some cases, we require more information and will request additional records so we can make a fully informed decision.