They may request or review medical records, test results and other information so they understand what services are being performed and are able to make an informed decision. 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. Below that, write the name of the requester (if different than the prescriber) and supply the prescribers NPI number and DEA number. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely. o Massachusetts Collaborative Prior Authorization Form or o Blue Cross Blue Shield of Massachusetts Pre-certification Request Form Click on the title for complete list of drugs that require prior authorization: Medical Benefit Prior Authorization Medication List, #034 Medical Utilization Management and Pharmacy Prior Authorization, #033 Please verify benefit coverage prior to rendering services. March 2023 Anthem Provider News - New Hampshire. Administrative. Prior Authorization Medication management With input from community physicians, specialty societies, and our Pharmacy & Therapeutics Committee, which includes community physicians and pharmacists from across the state, we design programs to help keep prescription drug coverage affordable. Prior authorization is the process of obtaining coverage approval for a medical or behavioral health service or procedure in advance of treatment. Learn more about electronic authorization. . Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital . | Medical Policy and Clinical Guideline updates are available on our provider website, AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List update, Enhancing Provider News website and email communications, Helping to reduce delays when submitting attachments: Make sure your correspondence includes one of these elements, Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines, Specialty pharmacy updates - February 2023, City of Manchester Offers Medicare Advantage Option - New Hampshire, Name change announcement: myNEXUS will transition to Carelon Post Acute Solutions on March 1, 2023, 2023 FEP benefit information available online, Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list (Fylnetra), Telephonic-only care allowance extended through April 11, 2023, Anthem Blue Cross and Blue Shield local precertification change in New Hampshire, Updates to AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines, New specialty pharmacy medical step therapy requirements, Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list, Notification regarding reimbursement changes to COVID-19 laboratory services codes, Submitting prior authorizations digitally through Interactive Care Reviewer, Outpatient facility revenue code billing requirements, AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT code list update, Update: AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List, Updates to AIM Specialty Health Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines, Updates to AIM Specialty Health Musculoskeletal - Interventional Pain Management Clinical Appropriateness Guidelines, Updates to AIM Specialty Health Cardiac Clinical Appropriateness Guidelines - Material adverse change, Medical policy and clinical guideline updates available on our provider website, Federal Employee Program observation conversion for musculoskeletal cases, Remittance advice message enhancements: Providing clear descriptions and actionable next steps, Childhood Immunization Status and Lead Screening in Children for HEDIS, Attention lab providers: COVID-19 update regarding reimbursement, December 2022 Provider Newsletter - New Hampshire, Important information about utilization management, IngenioRx will become CarelonRx on January 1, 2023, Reimbursement policy retirement: Acupuncture Billed with Evaluation and Management - Professional, Reimbursement policy update: Treatment Rooms with Office Evaluation and Management Services - Facility, Reimbursement policy update: Bundled Services and Supplies - Professional, Manchester School District in New Hampshire moves to the Medicare Advantage plan with Anthem Blue Cross and Blue Shield, 2023 Medicare Advantage service area and benefit updates, Signature requirements for laboratory orders or requisitions, Reminder - updated AIM Musculoskeletal program effective January 1, 2023 - site of care reviews, Specialty pharmacy updates - December 2022, AIM Specialty Health Genetic Testing Clinical Appropriateness Guidelines CPT Code List update, Member assessment of PCP after-hours messaging in 2022, Members assessment of behavioral healthcare after-hours messaging in 2022, CAA: Timely updates help keep our provider directories current, Clinical practice and preventive health guidelines available on anthem.com, Pharmacy information available on the provider website, PCP searches in Find Care - New Hampshire, Support documentation for AIM prior authorization requests, November 2022 Provider Newsletter - New Hampshire, Claims status message enhancements: providing clear descriptions and actionable next steps, Submit digital attachments within seven-calendar days for claims filed with a PWK segment indicator, You can now submit one electronic claim dispute for multiple claims and access correspondence digitally, too, Visit the Provider Learning Hub to view our latest learning opportunities, Correction to reimbursement policy: Place of Service - Facility, Transition to AIM Specialty Health Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline, Medical policy and clinical guideline updates available on anthem.com, Medical drug benefit Clinical Criteria updates, Post office boxes being retired because of low usage, Specialty pharmacy updates - November 2022, CAA: Keep your provider directory information up to date, Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022, COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022, Register for our upcoming CME webinar about low back pain management, CME webinar about low back pain management - New Hampshire, October 2022 Provider Newsletter - New Hampshire. In Indiana: Anthem Insurance Companies, Inc. Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Your contract lists covered services, like a wellness exam, immunization or a diagnostic test. You are invited: Advancing Mental Health Equity for Youth & Young Adults. 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. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. FEP utilizes Magellan Rx Management for medical, Providers requesting prior approval for an ASE/PSE member should use the appropriate form on the, Providers who are requesting a prior approval for Walmart or other BlueAdvantage members should use the appropriate form from the, Providers who are requesting a prior approval for BlueMedicare or Health Advantage Medicare Advantage members should use the appropriate form from, Providers requesting prior approval for Part B drugs for BlueMedicare or Health Advantage Medicare should use the, Name and telephone number of contact person, Requesting / Performing Providers NPI or Provider ID, Copy of members insurance card (front/back), CPT Code(s), ICD 10/HCPCS Code(s), Modifiers that are applicable, Please use the most descriptive procedure and diagnosis codes, Medical records to support requested services. Contact CVS Caremark by phone at 844-345-3241 or visit their website. | or sexual orientation.Premera Blue Cross HMO complies with applicablefederal and Washington state civil rights lawsand does not discriminate on the basis of race, Anthem is a registered trademark of Anthem Insurance Companies, Inc. This website is owned and operated by USAble Mutual Insurance Company, d/b/a Arkansas Blue Cross and Blue Shield. Availity is an independent provider of health information network services that does not provide Blue Cross Blue Shield products or services. We currently don't offer resources in your area, but you can select an option below to see information for that state. If you choose to access other websites from this website, you agree, as a condition of choosing any such ), 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation, 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach, 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach, 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach, 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy), 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis, 33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure), 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed, 33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle, 33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only, 36514 Therapeutic Apheresis; Plasma Pheresis, 37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection, 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed, A4224 Supplies for maintenance of insulin infusion catheter, per week, A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each, A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe, A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fah, A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each, A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries, C1722 Cardioverter-defibrillator, single chamber (implantable), L5671 Addition to lower extremity, below knee (BK)/above knee (AK) suspension locking mechanism (shuttle, lanyard, or equal), excludes socket insert, L5673 Addition to lower extremity, below knee/above knee, custom fabricated, L5679 Addition to lower extremity, below knee/above knee, custom fabricated, L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature, L5981 All lower extremity prostheses, flex-walk system or equal, L5987 All lower extremity prostheses, shank foot system with vertical loading pylon, L8699 Prosthetic implant, not otherwise specified, L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code. Weve provided the following resources to help you understand Anthems prior authorization process and obtain authorization for your patients when its required. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Have you reviewed your online provider directory information lately? of merchantability or fitness for a particular purpose, nor of non-infringement, with regard to the content Prior to surgical treatment of gender dysphoria in FEP members, you must submit a treatment plan, including all surgeries planned, and the estimated date each will be performed. 2023 Regence health plans are Independent Licensees of the Blue Cross and Blue Shield Association serving members in Idaho, Oregon, Utah and select counties of Washington. Located in neighborhoods all over the country, CareMore Health Care Centers combine a variety of different specialty services under one roof. Easily obtain pre-authorization and eligibility information with our tools. The Internet Explorer 11 browser application will be retired and go out of support on June 15, 2022. We deliver personalized healthcare the way you want it, where you need it: in our neighborhood Care Centers, in your own home, in hospitals or skilled nursing facilities. Use of the Anthem websites constitutes your agreement with our Terms of Use. under any circumstances for the activities, omissions or conduct of any owner or operator of any other third-party website link available as an option to you, ABCBS does not in any way endorse any such website, may be offered to you through such other websites or by the owner or operator of such other websites. Use Availity to submit prior authorizations and check codes. If you have any questions regarding our Utilization Management or Prior Authorization process, please call Customer Service at the number on the back of your identification card and they can answer any general inquiries you may have. 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. In the case of an emergency, you do not need prior authorization. If you're concerned about losing coverage, we can connect you to the right options for you and your family. View requirements for group and Individual members on our commercial products. TransactRx and CoverMyMeds are separate and independent companies that provide pharmacy pre-authorization and claims submission for Regence members. For both outpatient procedures and treatment requiring an inpatient stay, call (800) 633-4581 to obtain prior authorization. Step 10 On page 2 (1), select yes or no to indicate whether the patient has tried other medications for their condition. Visit Anthem.com to learn more about how we coordinate our medical and pharmacy benefits, review our drug lists, submit prior authorization requests, and more. We're here to work with you, your doctor and the facility so you have the best possible health outcome. Step 9 At the top of page 2, provide the patients name and ID number. website. Medical and Behavioral Health Procedure Codes Requiring Prior Authorization: Providers please note that as of the 2/1/2022 Prior Authorization release, we are moving to one document that includes authorization requirements for Medical, Durable Medical Equipment, eviCore, and Behavioral Health rather than individual documents for each specialty. The resources for our providers may differ between states. CareMore Health is a leading primary care provider that specializes in chronic and complex conditions. Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) has an online tool that displays prior authorization guidelines to help you quickly determine whether certain services for Anthem members require a prior authorization. Payments for services from a non-participating provider are generally sent to the member, except where federal or state mandates apply, or negotiated agreements are in place. L3927 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (for example, static or ring type), may include soft interface material, prefabricated, L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system, L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee, L5645 Addition to lower extremity, below knee (BK), flexible inner socket, external frame, L5649 Addition to lower extremity, ischial containment/narrow M-L socket, L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each, 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed, 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure. In Indiana: Anthem Insurance Companies, Inc. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Step 5 In Medication / Medical and Dispensing Information, specify the medication name and indicate whether or not the request is a new therapy or a renewal (if renewal, specifythe date therapy started and the duration). Prior authorization is not a guarantee of payment. You can also visit bcbs.com to find resources for other states. Type at least three letters and well start finding suggestions for you. 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. All rights reserved. Inpatient services and nonparticipating providers always require prior authorization. It is a pre-service determination of medical necessity based on information provided to Blue Cross of Idaho at the time the prior authorization request is made. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Federal Employee Program. Information about COVID-19 and your insurance coverage. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Prior authorization requests are submitted on different websites for Individual and non-Individual plan members (groups, associations, etc.). In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. There is a list of these services in your member contract. Use of the Anthem websites constitutes your agreement with our Terms of Use. In Ohio: Community Insurance Company. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at availity.com at anthem.com/medicareprovider > Login. Noncompliance with new requirements may result in denied claims. 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. Kreyl Ayisyen | 1 Services may be listed as requiring prior authorization that may not be covered benefits for a particular member. The resources for our providers may differ between states. In Kentucky: Anthem Health Plans of Kentucky, Inc. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. | You understand and agree that by making any Blue Cross of Idaho retains the right to review the medical necessity of services, eligibility for services and benefit limitations and exclusions after you receive the services. In Ohio: Community Insurance Company. Anthem Blue Cross Blue Shield: Health Insurance, Medicare & More Stay Covered When Medicaid Renewals Begin Medicaid renewals will start again soon. Use Availitys electronic authorization tool to quickly see if a pre-authorization is required for a medical service or submit your medical pre-authorization request. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. Step 11 On page 2 (2), list all diagnoses and provide theICD-9/ICD-10. Review requirements for Medicare Advantage members. To stay covered, Medicaid members will need to take action. Or if you are calling about a specific case, they will direct your call to the appropriate prior authorization staff. Choose your location to get started. 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. 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. 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. Log into the Members portal to view the status of your prior authorization under the Claims &Eligibility menu. Other Blue Plans pre-authorization requirements may differ from ours. 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. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Deutsch | Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at availity.com at anthem.com/medicareprovider > Login. Please note that CVS Caremark administers the pharmacy benefits for the State Health Benefit Plan. Submit a pharmacy pre-authorization through covermymeds.com or submit a claim with TransactRx. Our team of licensed physicians, registered nurses, or pharmacy technicians receive and review all prior authorization requests. 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. Anthem has also made available a series of forms for specific medications which may provide more efficient service when making a request. This helps address the issue of rising healthcare costs by keeping procedures and services that are not medically necessary from being performed. Updated June 02, 2022. Fax the completed form to 1-844-429-7757 within one business day of the determination/action. In Maine: Anthem Health Plans of Maine, Inc. Portugus | URAC Accredited - Health Plan with Health Insurance Marketplace (HIM) - 7.3, URAC Accredited - Health Utilization Management - 7.4, Member forms - Individual and family plans, Coverage policy and pre-certification/pre-authorization, Approval information for radiological services, Medicare Advantage Prior Authorization Request Form, Part B Medication Prior Approval Request Form, Check deductible and out-of-pocket totals. March 2023 Anthem Provider News - New Hampshire, February 2023 Provider Newsletter - New Hampshire, Telephonic-only care allowance extended through April 11, 2023 - New Hampshire, January 2023 Provider Newsletter - New Hampshire, Reimbursement for services by clinical behavioral health providers seeking licensure, Time to prepare for HEDIS medical record review, New policy for EMR clinical data sharing and ADT notifications, Reimbursement policy update: Modifiers 25 and 57 - Professional, Specialty pharmacy updates for March 2023, Clinical Criteria updates for specialty pharmacy. Select Auth/Referral Inquiry or Authorizations.

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