Medicaid Behavioral/Physical Health Coordination. 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. Information about benefits for your patients covered by the BlueCard program. 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. Administrative. 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. In the event of an emergency, members may access emergency services 24/7. Medicare Coverage with Anthem Medicare Information Medicare Coverage and Enrollment Turning 65 Medicare Advantage Plans: Part C Medicare Part D Plans Medicare Supplement Plans (Medigap) Dental and Vision Coverage CareCare What to Know Getting Better Care Preventive Health Find Care Medicare Caregiver Resources SupportSupport Login Registration BCBS FEP Vision covers frames, lenses, and eye exams. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Provider Enrollment Forms. * Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Do not sell or share my personal information. You can use the PriorAuthorizationLookupTool or reference the provider manual to determine if authorization is needed. Noncompliance with new requirements may result in denied claims. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. Details about new programs and changes to our procedures and guidelines. PPO outpatient services do not require Pre-Service Review. 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. We look forward to working with you to provide quality services to our members. 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. Select Auth/Referral Inquiry or Authorizations. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. In addition, some sites may require you to agree to their terms of use and privacy policy. 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. rationale behind certain code pairs in the database. Commercial. Drug list/Formulary inclusion does not infer a drug is a covered benefit. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). These documents contain information about upcoming code edits. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Providers should call the prior authorization number on the back of the member ID card. For your convenience, we've put these commonly used documents together in one place. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes. Prior authorization requirements will be added for the following codes: Not all PA requirements are listed here. This new site may be offered by a vendor or an independent third party. Use of the Anthem websites constitutes your agreement with our Terms of Use. %%EOF Not connected with or endorsed by the U.S. Government or the federal Medicare program. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. 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 This approval process is called prior authorization. In Maine: Anthem Health Plans of Maine, Inc. Code pairs reported here are updated quarterly based on the following schedule. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the members ID card. Please verify benefit coverage prior to rendering services. For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. Its important to remember that benefit plans differ in their benefits, and details such as prior authorization requirements are subject to change. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. The clinical editing rationale supporting this database is provided here to assist you in understanding the Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number, which can be found here. View the list of services below and click on the links to access the criteria used for Pre-Service Review decisions. Independent licensees of the Blue Cross Association. Availity Portal for behavioral health authorizations, or contactProviderServices for assistance. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. Contact will be made by an insurance agent or insurance company. 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. Some procedures may also receive instant approval. Here you'll find information on the available plans and their benefits. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. In Ohio: Community Insurance Company. Nov 1, 2021 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 Follow the step-by-step instructions below to design your anthem forms: Select the document you want to sign and click Upload. In Ohio: Community Insurance Company. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Commercial Prior Authorization Summary and Code Lists hbbd```b``+d3d] fIM|0+d:"Y`XM7`D2HO H2Xb R?H?G _q Prior Authorization. Musculoskeletal (eviCore): 800-540-2406. Effective 01/01/2023 (includes changes effective 04/01/2023) . Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. We've provided the following resources to help you understand Empire's prior authorization process and obtain authorization for your patients when it's . %PDF-1.6 % 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. Updated June 02, 2022. Contact 866-773-2884 for authorization regarding treatment. Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. 494 0 obj <>stream 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Choose My Signature. The Anthem Alliance EPO 2022 prior authorization list has been updated effective January 1, 2022. 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. 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. Inpatient services and nonparticipating providers always require prior authorization. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. 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. Here youll find information on the available plans and their benefits. Fax medical prior authorization request forms to: 844-864-7853 eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. Effective 01/01/2022 - 09/17/2022; Prior Authorization Procedure Codes List for ASO Plans. Please refer to the criteria listed below for genetic testing. Inpatient services and nonparticipating providers always require prior authorization. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Get the latest news to help improve your life and keep you healthy. To get started, select the state you live in. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ICR in Availityfor all notifications or prior authorization requests, including reporting a members pregnancy. 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). One option is Adobe Reader which has a built-in reader. . Independent licensees of the Blue Cross Association. Medical Injectable Drugs: 833-581-1861. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. This list contains notification/prior authorization requirements for inpatient and outpatient services. 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. Anthem offers great healthcare options for federal employees and their families. 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. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans Anthem offers great healthcare options for federal employees and their families. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. 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. 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 Future updates regarding COVID-19 will appear in the monthly Provider News publication. Availity provides administrative services to BCBSIL. In 2020, Part B step therapy may apply to some categories . Please refer to the criteria listed below for genetic testing. Providers are responsible for verifying prior authorization requirements before services are rendered. 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. 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. 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. CareFirst does not guarantee that this list is complete or current. Providers should continue to verify member eligibility and benefits prior to rendering services. This step will help you determine if prior authorization may be required for a specific member and service. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Independent licensees of the Blue Cross and Blue Shield Association. 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. The aforementioned legal entities, CareFirst BlueChoice, Inc., and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. Anthem does not require prior authorization for treatment of emergency medical conditions. Contact 866-773-2884 for authorization regarding treatment. 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. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. Prior authorization list. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Independent licensees of the Blue Cross and Blue Shield Association. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. Rx Prior Authorization. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. The "Prior authorization list" is a list of designated medical and surgical services and select prescription Drugs that require prior authorization under the medical benefit. 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. This approval process is called prior authorization. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. 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. 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. Home Health/Home Infusion Therapy/Hospice: 888-567-5703. We look forward to working with you to provide quality service for our members. 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. 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