The purpose of this communication is the solicitation of insurance. 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021. Independent licensees of the Blue Cross Association. In Indiana: Anthem Insurance Companies, 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. PPO outpatient services do not require Pre-Service Review. 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. Prior Authorization Requirements. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Here youll find information on the available plans and their benefits. Information about benefits for your patients covered by the BlueCard program. In Kentucky: Anthem Health Plans of Kentucky, Inc. Attention: If you speak any language other than English, language assistance services, free of charge, are available to you. Fax medical prior authorization request forms to: 844-864-7853 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. One option is Adobe Reader which has a built-in reader. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Please use the Mar 1, 2022 Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2022. Use Availity's electronic authorization tool to quickly see if a pre-authorization is required for a medical service or submit your medical pre-authorization request. External link You are leaving this website/app (site). Learn about the NAIC rules regarding coordination of benefits. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Online - The AIM ProviderPortal is available 24x7. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem Blue Cross and Blue Shield. 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. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. Here are links to some recent communications that were posted to notify you of important changes: Government Programs Prior Authorization Summary and Code Lists Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. BlueCross BlueShield of Tennessee uses a clinical editing database. To get started, select the state you live in. This list contains notification/prior authorization requirements for inpatient and outpatient services. Commercial Prior Authorization Summary and Code Lists %PDF-1.6 % 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. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. Type at least three letters and well start finding suggestions for you. CoverKids. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. Third-Party Liability (TPL) Forms. Forms and information about behavioral health services for your patients. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Look up common health coverage and medical terms. You can also check status of an existing request and auto-authorize more than 40 common procedures. Access the BH Provider Manuals, Rates and Resources webpage here. Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. 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. 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. Rx Prior Authorization. Please Select Your State The resources on this page are specific to your state. Scroll down to the table of contents. 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. PPO outpatient services do not require Pre-Service Review. Administrative. Anthem does not require prior authorization for treatment of emergency medical conditions. Updated June 02, 2022. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans 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. Nov 1, 2021 In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. ). Select Auth/Referral Inquiry or Authorizations. Use the Prior Authorization tool within Availity, or Contact Provider Services To submit a precertification request: Log in to Availity. Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. Blue Cross and Blue Shield of Illinois, aDivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. BCBS FEP Vision covers frames, lenses, and eye exams. Pharmacy Forms. The services marked with an asterisk (*) only require Pre-Service Review for members enrolled in BlueChoice products if performed in an outpatient setting that is on the campus of a hospital. 0 COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Provider Enrollment Forms. Musculoskeletal (eviCore): 800-540-2406. Its critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. Independent licensees of the Blue Cross and Blue Shield Association. 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 Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. CareFirst Commercial Pre-Service Review and 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. In Maine: Anthem Health Plans of Maine, Inc. Prior authorization list. Inpatient services and nonparticipating providers always require prior authorization. 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. Independent licensees of the Blue Cross Association. 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. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Large Group This tool is for outpatient services only. The clinical editing rationale supporting this database is provided here to assist you in understanding the 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. Start by choosing your patient's network listed below. To get started, select the state you live in. 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. The site may also contain non-Medicare related information. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Please refer to the criteria listed below for genetic testing. Providers should continue to verify member eligibility and benefits prior to rendering services. Some procedures may also receive instant approval. Or 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. Long-Term Care (LTC) Forms. Noncompliance with new requirements may result in denied claims. Please reference the Blues & CDHP Products Prior Authorization List on the Prior Authorization webpage. Medical Injectable Drugs: 833-581-1861. Medicare Advantage. 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. The latest edition and archives of our quarterly quality newsletter. 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 approval process is called prior authorization. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Effective 01/01/2023 (includes changes effective 04/01/2023) . 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. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. hb``` ce`a`Y5 bR;)/}ksN}J^dcZ9@ @Hw400P`a Pl fKU0 e`c cpIqc1$frf3Hf6S\k{3*0ue`dzAyF ~ H00#9 L 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. 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. Contact 866-773-2884 for authorization regarding treatment. rationale behind certain code pairs in the database. These manuals are your source for important information about our policies and procedures. For more information, please refer to the Medical Policy Reference Manual. 2022 Standard Pre-certification list . Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. 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. 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. Decide on what kind of signature to create. 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. In 2020, Part B step therapy may apply to some categories . If you have any questions, call the number on the members ID card. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 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. Prior Authorization. endstream endobj startxref The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are the business names of First Care, Inc. Anthem offers great healthcare options for federal employees and their families. In Connecticut: Anthem Health Plans, Inc. 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 Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 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. 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