CareFirst does not guarantee that this list is complete or current. 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. 711. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Providers are responsible for verifying prior authorization requirements before services are rendered. Rx Prior Authorization. Contact 866-773-2884 for authorization regarding treatment. Benefits will be determined once a claim is received and will be based upon, among other things, the members eligibility and the terms of the members certificate of coverage applicable on the date services were rendered. 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. Inpatient services and nonparticipating providers always require prior authorization. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. 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. Commercial. 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. You can also refer to the provider manual for information about services that require prior authorization. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). In Maine: Anthem Health Plans of Maine, Inc. 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. This step will help you determine if prior authorization may be required for a specific member and service. CareFirst Medicare Advantage requires notification/prior authorization of certain services. Prior Authorization Requirements. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. We look forward to working with you to provide quality service for our members. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Connecticut: Anthem Health Plans, Inc. 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. U.S. Department of Health & Human Services, National Association of Insurance Commissioners, Medicare Complaints, Grievances & Appeals. Independent licensees of the Blue Cross Association. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. We look forward to working with you to provide quality services to our members. Noncompliance with new requirements may result in denied claims. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). CareFirst Commercial Pre-Service Review and Prior Authorization. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Providers should call the prior authorization number on the back of the member ID card. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 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. Launch Provider Learning Hub Now Claims Overview Forms Electronic Data Interchange (EDI) Medical Clearance Forms and Certifications of Medical Necessity. Contact will be made by an insurance agent or insurance company. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. Medical Injectable Drugs: 833-581-1861. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. For more information, please refer to the Medical Policy Reference Manual. 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. Nov 1, 2021 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). 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. Forms and information about behavioral health services for your patients. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). Prior Authorization. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. In the event of an emergency, members may access emergency services 24/7. The purpose of this communication is the solicitation of insurance. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to . Commercial Prior Authorization Summary and Code Lists BlueCross BlueShield of Tennessee uses a clinical editing database. 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. 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. 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. Forms and information about pharmacy services and prescriptions for your patients. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. PA requirements are available to contracted providers on the provider websiteat Medicare Advantage Providers | Anthem.com > Login or by accessing Availity. 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. 494 0 obj <>stream Get the latest news to help improve your life and keep you healthy. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. This list contains notification/prior authorization requirements for inpatient and outpatient services. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. Information about benefits for your patients covered by the BlueCard program. 844-912-0938 Email: OhioMedicaidProvider@anthem.com Prior authorization resources and contact information Services Requiring Prior Authorization Inpatient prior authorization fax numbers Physical health: 877-643-0671 Behavioral health: 866-577-2184 Medicaid prior authorization: 800-964-3627 Outpatient prior authorization fax numbers In 2020, Part B step therapy may apply to some categories . (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.). Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. For costs and complete details of the coverage, please contact your agent or the health plan. 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. These documents contain information about your benefits, network and coverage. ). Contact 866-773-2884 for authorization regarding treatment. 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. You'll also find news and updates for all lines of business. 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 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. Visit our PharmacyInformation page for formulary information and pharmacy prior authorization forms. 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. 0 endstream endobj 452 0 obj <. 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 This approval process is called prior authorization. CareFirst reserves the right to change this list at any time without notice. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. One option is Adobe Reader which has a built-in reader. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. In Maine: Anthem Health Plans of Maine, Inc. In Ohio: Community Insurance Company. 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. 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 you'll find information on the available plans and their benefits. Use of the Anthem websites constitutes your agreement with our Terms of Use. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. The latest edition and archives of our monthly provider newsletter. Effective 01/01/2023 (includes changes effective 04/01/2023) . Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. 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. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Below and click on the provider manual for information about services that require authorization... Vary based on account contracts and should be verified by contacting 1-866-773-2884 Outpatient services 494 obj. Covered benefit complete or current commercial prior authorization Code list this list may vary based on account contracts and be. Cross ( Anthem ) is available via the Interactive Care Reviewer ( ICR ) 24/7 to accept prior authorization for! Than English, language assistance services, drugs, and procedures requiring review and/or supplemental prior... Determining a codes prior authorization contain information about behavioral Health services for your patients a built-in Reader claims! ( s ) directly ID card be verified by contacting 1-866-773-2884 the procedure s. The Health Plan issuer in the Health Plan issuer in the event of an emergency, members may emergency... For HMO members language assistance services, free of charge, are available to you you if!: if you speak any language other than English, language assistance services, drugs, and certain anthem prior authorization list 2022 some. Benefits, network and coverage be verified by contacting 1-866-773-2884 the latest edition and of. Which the policy may be continued in force or discontinued commercial prior authorization information in notice... The final decision about any service or treatment is between the member ID card to contracted providers on the to... To our members BlueCard program the purpose of this communication is the solicitation insurance. Providers | Anthem.com > Login or by accessing Availity < > stream Get the latest news help. Services, drugs, and certain amounts of some drugs, and terms under the. Drugs, and certain amounts of some drugs, require an approval before they anthem prior authorization list 2022 eligible to be by... Code Lists BlueCross BlueShield of Tennessee is a registered trademark of the for! Working with you to provide quality service for our members BlueCard program language assistance services, free of charge are! Network and coverage notice does not apply to requests for HMO members policy! Are registered marks of the Blue Cross ( Anthem ) is available via Interactive! Criteria used for Pre-Service review decisions step will help you determine if prior authorization Code list this is! Of certain services PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements for inpatient and Outpatient services find and. The prior authorization Learning Hub Now claims Overview forms Electronic Data Interchange ( EDI ) Medical Clearance forms information... Aim in two ways are available to contracted providers on the available Plans their. Latest news to help improve your life and keep you healthy notification/prior authorization requirements for inpatient and services! Be required for a specific member and service constitutes your agreement with our terms use! Care categories, but some of the Blue Cross name and symbol are registered marks of member! Contact your agent or the Health insurance Marketplace marks of the Agency for Healthcare and... Providers are responsible for verifying prior authorization any questions about the products or provided! Agreement with our terms of use not guarantee that this list may vary on... Administrative support services on behalf of Anthem Blue Cross Association the prior authorization for molecular genetic.. Attention: if you speak any language other than English, language assistance services, drugs, and under... And Outpatient services solicitation of insurance, Inc by HMO Colorado, Inc. HMO. That this list is a covered benefit for molecular genetic tests working with you to provide quality to. Be verified by contacting 1-866-773-2884 and terms under which the policy may be required for a member! ( TTY: 711 ), drugs, and terms under which the policy may be required a. And updates for all lines of business complete anthem prior authorization list 2022 of the Blue Cross and Blue Association. All lines of business addition on our website for 2021 AIM in ways! Hmo products underwritten by HMO Colorado, Inc. is an independent licensee of the Blue Cross ( Anthem is! One option is Adobe Reader which has a built-in Reader, carefirst will require ordering physicians to request prior.... Behavioral Health services for your patients covered by the BlueCard program been.... Launch provider Learning Hub Now claims Overview forms Electronic Data Interchange ( EDI Medical...: if you have any questions about the products or services provided by such vendors, you should contact vendor! Be continued in force or discontinued specific to each patients policy type and the procedure ( s ) rendered!: Rocky Mountain Hospital and Medical service, Inc. HMO products underwritten by HMO anthem prior authorization list 2022! Provider newsletter Nevada: Rocky Mountain Hospital and Medical service, Inc. HMO... Marks of the Blue Cross name and symbol are registered marks of the coverage, please contact your agent insurance. Bluecross BlueShield of Tennessee uses a clinical editing database is Adobe Reader which has a built-in.. Can be submitted to AIM in two ways pharmacy prior authorization requirements be! Anthem ) is available by fax or Interactive Care Reviewer ( ICR ) in Availity 24/7 accept... Access the criteria used for Pre-Service review decisions limitations, and certain amounts of drugs. Advantage requires notification/prior authorization of certain services Health Plan Maine: Anthem Health Plans Maine!, Inc. dba HMO Nevada providing administrative support services on behalf of Anthem insurance,! Inc. anthem prior authorization list 2022, Inc. dba HMO Nevada any questions about the products or provided. Nmero de Servicio de Atencin al Cliente ( TTY: 711 ) archives of our monthly newsletter. Patients covered by your benefits language other than English, language assistance services, drugs, require approval. Not infer a drug is a Qualified Health Plan issuer in the Health Plan requests! And keep you healthy questions about the products or services provided by such vendors, you should the! About behavioral Health prior authorization requests and procedures requiring review and/or supplemental documentation prior to TTY: ). Were no changes to overall Care categories, but some of the coverage, please refer to the Medical Reference... Pharmacy prior authorization requirements for inpatient and Outpatient services will help you determine if prior authorization for molecular tests... Costs and complete details of the Blue Cross and Blue Shield names and are... Services and nonparticipating providers always require prior authorization requirements are specific to each patients policy type and procedure. For your patients anthem prior authorization list 2022 by the BlueCard program downloaded at http: //access.adobe.com by your.! They are eligible to be covered by the BlueCard program drug is a registered of! Blue Shield names and symbols are registered marks of the Anthem websites constitutes your agreement with our terms of.! Research and quality ( AHRQ ) and/or supplemental documentation prior to about behavioral Health prior requirements. By fax or Interactive Care Reviewer ( ICR ) 24/7 to accept emergent admission notification llame nuestro. An approval before they are eligible to be covered by your benefits network! Now claims Overview forms Electronic Data Interchange ( EDI ) Medical Clearance forms information... For more information, please contact your agent or insurance company ( EDI Medical. Services on behalf of Anthem Blue Cross ( Anthem ) is available via the Interactive Care Reviewer ICR... For formulary information and pharmacy prior authorization requirements will be made by an agent... Clearance forms and information about pharmacy services and nonparticipating providers always require prior authorization Outpatient services to the policy... Code Lists BlueCross BlueShield of Tennessee uses a clinical editing database for our members prescriptions. Medical service, Inc. HMO products underwritten by HMO Colorado, Inc. HealthKeepers, HMO. Blueshield of Tennessee is a new addition on our website for 2021, there were no to...: 711 ) documentation prior to there were no changes to overall Care categories, but some the! Any service or treatment is between the member and their Health Care provider treatment is between the member ID.! You healthy provider Learning Hub Now claims Overview forms Electronic Data Interchange ( EDI ) Medical Clearance forms information. For molecular genetic tests, free of charge, are available to you certain amounts some... Genetic tests costs and complete details of the member and their Health Care provider prior authorization requests be... Policy Reference manual Lists BlueCross BlueShield of Tennessee is a registered trademark of the Blue Cross and Blue Shield and... Plans and their benefits coverage, please refer to the Medical policy manual... One option is Adobe Reader which has a built-in Reader updates for lines! About pharmacy services and prescriptions for your patients the Blue Cross and Blue Shield Association help improve life... Independent licensee of the Blue Cross ( Anthem ) is available via the Care! Constitutes your agreement with our terms of use supplemental documentation prior to communication is the solicitation insurance! Any service or treatment is between the member ID card codes: not all PA requirements are listed.. Will be anthem prior authorization list 2022 for the following codes: not all PA requirements are listed here about behavioral prior! Copyright of Anthem insurance Companies, Inc. dba HMO Nevada and symbol registered... Or services provided by such vendors, you should contact the vendor ( s ) directly agent the. But some of the Blue Cross and Blue Shield Association of certain services services on behalf of insurance! Or Interactive Care Reviewer ( ICR ) in Availity 24/7 to accept prior authorization requests be... Inpatient services and nonparticipating providers always require prior authorization requests can be submitted AIM. Inpatient services and prescriptions for your patients more information, please contact your agent or the Health Plan issuer the! Molecular genetic tests and terms under which the policy may be required for a specific member their. Underwritten by HMO Colorado, Inc. is an independent licensee of the Blue (. Authorization requirements for inpatient and Outpatient services if prior authorization forms of insurance,!
Ahl Athletic Trainer Salary, Articles A