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. This approval process is called prior authorization. Noncompliance with new requirements may result in denied claims. This list may vary based on account contracts and should be verified by contacting 1-866-773-2884. For more information, please refer to the Medical Policy Reference Manual. Do not sell or share my personal information. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as eviCore, AIM or Availity. As your health needs evolve, our diverse plans are designed to evolve with you. ICR offers a fast, efficient way to securely submit prior authorization requests with clinical documentation. 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. 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 * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Anthem does not require prior authorization for treatment of emergency medical conditions. Nov 1, 2021 In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. 711. 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. To get started, select the state you live in. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. The site may also contain non-Medicare related information. Code pairs reported here are updated quarterly based on the following schedule. You can also check status of an existing request and auto-authorize more than 40 common procedures. Details about new programs and changes to our procedures and guidelines. Anthem is a registered trademark of Anthem Insurance Companies, Inc. We look forward to working with you to provide quality services to our members. Independent licensees of the Blue Cross Association. The purpose of this communication is the solicitation of insurance. 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. %PDF-1.6 % This new site may be offered by a vendor or an independent third party. You can also refer to the provider manual for information about services that require prior authorization. Expedited fax: 888-235-8390. CareFirst does not guarantee that this list is complete or current. BlueCross BlueShield of Tennessee uses a clinical editing database. Contact 866-773-2884 for authorization regarding treatment. 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. Forms and information about pharmacy services and prescriptions for your patients. The BH prior authorization policy is outlined in the BH Provider Manual and can be accessed by following the instructions below. Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the shared business name of CareFirst Advantage, Inc. and CareFirst Advantage DSNP, Inc. CareFirst BlueCross BlueShield Community Health Plan Maryland is the business name of CareFirst Community Partners, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. 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. For costs and complete details of the coverage, please contact your agent or the health plan. This list contains notification/prior authorization requirements for inpatient and outpatient services. BCBS FEP Vision covers frames, lenses, and eye exams. If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. 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 The Blue Cross name and symbol are registered marks of the Blue Cross Association. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Providers should continue to verify member eligibility and benefits prior to rendering services. PPO outpatient services do not require Pre-Service Review. Drug list/Formulary inclusion does not infer a drug is a covered benefit. 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. Use of the Anthem websites constitutes your agreement with our Terms of Use. Independent licensees of the Blue Cross and Blue Shield Association. Note: Blue High Performance NetworkSM (BlueHPNSM) members have limited benefits at the University of Maryland Medical System Downtown Campus. Under the "Manuals" heading, click on the blue "Behavioral Health Provider Manual" text. These documents contain information about your benefits, network and coverage. 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. In Ohio: Community Insurance Company. In Ohio: Community Insurance Company. Here youll find information on the available plans and their benefits. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Providers should call the prior authorization number on the back of the member ID card. 2022 Standard Pre-certification list . Prior Authorization Requirements. Look up common health coverage and medical terms. (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.). 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. Inpatient services and nonparticipating providers always 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. 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. 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. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Prior authorization requirements are specific to each patients policy type and the procedure(s) being rendered. Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare. 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. 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. Home Health/Home Infusion Therapy/Hospice: 888-567-5703. 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.). 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. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Forms and information about behavioral health services for your patients. Medicare Advantage Providers Anthem offers a variety of Medicare plans to support member needs. 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 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. This approval process is called prior authorization. State & Federal / Medicare. Independent licensees of the Blue Cross Association. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. 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. 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 The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply. Here you'll find information on the available plans and their benefits. To view the medical policies associated with each service, click the link or search for the policy number in the Medical Policy Reference Manual. 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. 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 Summary and Code Lists 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021. 494 0 obj <>stream Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 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. 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. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). This tool is for outpatient services only. 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. Drug list/Formulary inclusion does not infer a drug is a covered benefit. In Connecticut: Anthem Health Plans, Inc. CareFirst Medicare Advantage requires notification/prior authorization of certain services. Availity provides administrative services to BCBSIL. Type at least three letters and well start finding suggestions for you. 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