Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Musculoskeletal (eviCore): 800-540-2406. Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. The Blue Cross name and symbol are registered marks of the Blue Cross Association. You may also view the prior approval information in the Service Benefit Plan Brochures. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Providers should continue to verify member eligibility and benefits prior to rendering services. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q Third-Party Liability (TPL) Forms. Noncompliance with new requirements may result in denied claims. In Connecticut: Anthem Health Plans, Inc. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. 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. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. 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. Call our Customer Service number, (TTY: 711). 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. Look up common health coverage and medical terms. You'll also find news and updates for all lines of business. 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. CareFirst Commercial Pre-Service Review and Prior Authorization. To get started, select the state you live in. The site may also contain non-Medicare related information. In Maine: Anthem Health Plans of Maine, Inc. For your convenience, we've put these commonly used documents together in one place. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Inpatient services and nonparticipating providers always require prior authorization. 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. 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 PPO outpatient services do not require Pre-Service Review. Availity provides administrative services to BCBSIL. Long-Term Care (LTC) Forms. Details about new programs and changes to our procedures and guidelines. 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. Scroll down to the table of contents. Please check your schedule of benefits for coverage information. Updated June 02, 2022. Prior Authorization (Nonpharmacy) Provider Correspondence Forms. CareFirst reserves the right to change this list at any time without notice. These documents contain information about your benefits, network and coverage. Pharmacy Forms. Administrative. This approval process is called prior authorization. State & Federal / Medicare. In Ohio: Community Insurance Company. %PDF-1.6 % 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 Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). Independent licensees of the Blue Cross Association. This step will help you determine if prior authorization may be required for a specific member and service. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Use of the Anthem websites constitutes your agreement with our Terms of Use. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Referencing the . 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. Providers should continue to verify member eligibility and benefits prior to rendering services. 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. Expedited fax: 888-235-8390. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. 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. To view this file, you may need to install a PDF reader program. 494 0 obj <>stream Here you'll find information on the available plans and their benefits. Providers should call the prior authorization number on the back of the member ID card. In Connecticut: Anthem Health Plans, Inc. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L 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). We look forward to working with you to provide quality service for our members. 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. 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. endstream endobj 452 0 obj <. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Home Health/Home Infusion Therapy/Hospice: 888-567-5703. 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. 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. Effective 01/01/2023 (includes changes effective 04/01/2023) . Learn about the NAIC rules regarding coordination of benefits. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. 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 Choose My Signature. Forms and information to help you request prior authorization or file an appeal. 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 new site may be offered by a vendor or an independent third party. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. We encourage providers to use ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. 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. Forms and information about pharmacy services and prescriptions for your patients. 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.). 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. endstream endobj startxref Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. In Ohio: Community Insurance Company. 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. Plans for federal employees, retirees, retired uniformed service members, and active duty family members. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. You can also refer to the provider manual for information about services that require prior authorization. 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. 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. It clarifies a utilization management vendor change for specific members. 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. 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. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. These manuals are your source for important information about our policies and procedures. Please refer to the criteria listed below for genetic testing. 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). Access the BH Provider Manuals, Rates and Resources webpage here. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. rationale behind certain code pairs in the database. BCBS FEP Vision covers frames, lenses, and eye exams. In Indiana: Anthem Insurance Companies, Inc. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 2022 Standard Pre-certification list . 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. In Indiana: Anthem Insurance Companies, Inc. Prior Authorization. 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. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Independent licensees of the Blue Cross Association. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. This approval process is called prior authorization. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Anthem offers great healthcare options for federal employees and their families. Anthem does not require prior authorization for treatment of emergency medical conditions. Information to help you maximize your performance in our quality programs. (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. Providers are responsible for verifying prior authorization requirements before services are rendered. The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. For costs and complete details of the coverage, please contact your agent or the health plan. You can also check status of an existing request and auto-authorize more than 40 common procedures. The latest edition and archives of our monthly provider newsletter. Inpatient services and nonparticipating providers always require prior authorization. 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. National Accounts, Posts about using health Insurance and managing your health, Collections of learning resources and links to services, For Sydney Health users connect with others and find care programs. Online - The AIM ProviderPortal is available 24x7. CareFirst Medicare Advantage requires notification/prior authorization of certain services. In 2020, Part B step therapy may apply to some categories . Bundling Rationale (Claims filed before Aug. 25, 2017). Select Auth/Referral Inquiry or Authorizations. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Most PDF readers are a free download. Select Patient Registration from the top navigation. Commercial 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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. 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 the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. We look forward to working with you to provide quality services to our members. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. Inpatient Clinical: 800-416-9195. Code pairs reported here are updated quarterly based on the following schedule. Large Group 711. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. Here youll find information on the available plans and their benefits. 451 0 obj <> endobj We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . We look forward to working with you to provide quality services to our members. 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. Use of the Anthem websites constitutes your agreement with our Terms of Use. Please verify benefit coverage prior to rendering services. Sign up to receive personalized communication from us, and we'll refine it to meet your preferences. Contact 866-773-2884 for authorization regarding treatment. CoverKids. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. Prior Authorization Requirements. Type at least three letters and well start finding suggestions for you. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. 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. Mar 1, 2022 Commercial. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. 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. 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. 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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