Step 13 The prescriber must provide their signature at the bottom of the form and the date of signing. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Let us know! 2022 Electronic Forms LLC. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements. Prior authorization requests are submitted on different websites for Individual and non-Individual plan members (groups, associations, etc.). Carelon Medical Benefits Management, Inc. You are invited: Advancing Mental Health Equity for Youth & Young Adults, Reminder: Updated Carelon Medical Benefits Management, Inc. Musculoskeletal Program effective April 1, 2023 - Site of care reviews, Carelon Medical Benefits Management (formerly AIM Specialty Health) Radiology Clinical Appropriateness Guidelines CPT code list update, Provider directory - annual audit for NCQA Accreditation, Statin Therapy Exclusions for Patients With Cardiovascular Disease/Diabetes HEDIS measures, March is National Colorectal Cancer Awareness Month, Reminder - Updated Carelon Musculoskeletal Program effective April 1, 2023: monitored anesthesia care reviews, Consumer payment option, Pay Doctor Bill, to terminate effective March 31, 2023, Pharmacy information available on our provider website, Controlling High Blood Pressure and Submitting Compliant Readings, Shared savings and transition care management after inpatient discharges. affiliates, its directors, officers, employees and agents ("the ABCBS Parties") are not responsible for Anthem does not require prior authorization for treatment of emergency medical conditions. 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 Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. 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. Looks like you're using an old browser. In Indiana: Anthem Insurance Companies, Inc. Select Auth/Referral Inquiry or Authorizations. Fax the completed form to 1-844-429-7757 within one business day of the determination/action. Or if you are calling about a specific case, they will direct your call to the appropriate prior authorization staff. An Independent Licensee of the Blue Cross and Blue Shield Association, Summary of Benefits & Coverage Information, Sleep Testing and Therapy & Advanced Imaging, Confirm your specific treatment plan and medical necessity given your diagnosis, Determine if services are eligible for coverage, Assure your claims are processed accurately and timely, Save you from unnecessary medical expenses. Independent licensees of the Blue Cross and Blue Shield Association. 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. nor state or imply that you should access such website or any services, products or information which Prior Authorization details for providers outside of WA/AK. Choose your location to get started. March 2023 Anthem Provider News - New Hampshire. However, if you receive services that are not medically necessary from a provider not contracting with Blue Cross of Idaho, you may be responsible for the entire cost of the services. Learn more about electronic authorization. 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 Ohio: Community Insurance Company. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. The Blue Cross name and symbol are registered marks of the Blue Cross Association. The resources for our providers may differ between states. Select Auth/Referral Inquiry or Authorizations. Step 3 In Insurance Information, provide the primary and secondary insurance providersalong with the corresponding patient ID numbers. We currently don't offer resources in your area, but you can select an option below to see information for that state. 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. Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association and is licensed to offer health plans in all 75 counties of Arkansas. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Espaol | Secondly, it can be frustrating when a service not covered by your contract is performed by your doctor or specialist. Kreyl Ayisyen | In Ohio: Community Insurance Company. In Maine: Anthem Health Plans of Maine, Inc. In Ohio: Community Insurance Company. Use of the Anthem websites constitutes your agreement with our Terms of Use. An Anthem(Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patients prescription cost. 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. We're here to work with you, your doctor and the facility so you have the best possible health outcome. Our team of licensed physicians, registered nurses, or pharmacy technicians receive and review all prior authorization requests. | To stay covered, Medicaid members will need to take action. More prior authorization resources Sign in to Availity Franais | Submit a pharmacy pre-authorization through covermymeds.com or submit a claim with TransactRx. 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. Step 11 On page 2 (2), list all diagnoses and provide theICD-9/ICD-10. Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. Register today for the Advancing Mental Health Equity for Youth & Young Adults forum hosted by Anthem Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on March 15, 2023. Use of the Anthem websites constitutes your agreement with our Terms of Use. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., independent licensee of the Blue Cross and Blue Shield Association. It looks like you're outside the United States. Commercial non-HMO prior authorization requests can be submitted to AIM in two ways. 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. 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. You can access the Precertification Lookup Tool through the Availity Portal. 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. Polski | Anthem has also made available a series of forms for specific medications which may provide more efficient service when making a request. This form should only be used for Arkansas Blue Cross and Blue Shield members. You further agree that ABCBS and its Sign in to the appropriate website to complete your request. You can also refer to the provider manual for information about services that require prior authorization. Use the search tool to find the Care Center closest to you. Independent licensees of the Blue Cross Association. Get Started Prior authorization contacts vary for Shared Administration groups.View the Shared Administration contact list for details. Oromoo | Contact CVS Caremark by phone at 844-345-3241 or visit their website. Italiano | TransactRx and CoverMyMeds are separate and independent companies that provide pharmacy pre-authorization and claims submission for Regence members. of all such websites. Non-individual members Use Availity to submit prior authorizations and check codes. Expand All You can also visit bcbs.com to find resources for other states It looks like you're outside the United States. 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. The formcontains important information regarding the patients medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patients health care plan. or sexual orientation.Premera Blue Cross HMO complies with applicablefederal and Washington state civil rights lawsand does not discriminate on the basis of race, | Please note that CarelonRx is the pharmacy benefits manager for Medicare Advantage plans. Contracted and non-contracted providers who are unable to access Availity* may call the number on the back of the members ID card. 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. We look forward to working with you to provide quality service for our members. 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. If you're concerned about losing coverage, we can connect you to the right options for you and your family. Please verify benefit coverage prior to rendering services. Tagalog | | In Maine: Anthem Health Plans of Maine, Inc. Weve provided the following resources to help you understand Anthems prior authorization process and obtain authorization for your patients when its required. Availity is an independent provider of health information network services that does not provide Blue Cross Blue Shield products or services. InteractiveCare Reviewer is a utilization management tool that lets you submit prior authorization requests and other clinical information quickly and easily. 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. Log into the Members portal to view the status of your prior authorization under the Claims &Eligibility menu. Prior authorization is required for surgical services only. 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. In Connecticut: Anthem Health Plans, Inc. Step 4 In Prescriber Information, specifythe prescribers full name, speciality, and full address. 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. You can also visit bcbs.com to find resources for other states. Contracted and non-contracted providers who are unable to access Availity* may call the number on the back of the member's ID card. L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, L3925 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf. 1 Services may be listed as requiring prior authorization that may not be covered benefits for a particular member. We currently don't offer resources in your area, but you can select an option below to see information for that state. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The team reviews the requested service(s), determines if it is medically necessary and if the service is covered under your insurance plan. Some procedures may also receive instant approval. 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. Denial of MH-TCM services is defined as the initial determination that a member does not meet the criteria for MH-TCM services. Also, specify any allergies and give the name and phone number of the patients authorized representative (if applicable). Type at least three letters and well start finding suggestions for you. Below that, write the name of the requester (if different than the prescriber) and supply the prescribers NPI number and DEA number. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. 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. We also want to ensure you receive the right technology that addresses your particular clinical issue. Our electronic prior authorization (ePA) process is the preferred method for . Prior Authorization Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). If we deny your request for coverage or you have questions regarding your prior authorization, please call Blue Cross of Idahos Customer Service. With prior authorization, Blue Cross of Idaho is able to: Prior authorization is just one of the ways we're working to save our members money and address rising healthcare costs. Find care, claims & more with our new app. 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. Prior authorization contact information for Empire Providers and staff can also contact Empire for help with prior authorization via the following methods: Empire Provider Services Phone: 1-800-450-8753 Hours: Monday to Friday 8:30 a.m. to 5:30 p.m. Fax: 1-800-964-3627 Empire Pharmacy Department In Indiana: Anthem Insurance Companies, Inc. | under any circumstances for the activities, omissions or conduct of any owner or operator of any other Please verify benefit coverage prior to rendering services. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Anthems PriorAuthorizationLookupToolOnlinecan assist with determining a codes prior authorization requirements. . The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Important: Blueprint Portal will not load if you are using Internet Explorer. The resources for our providers may differ between states. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, 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. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at availity.com at anthem.com/medicareprovider > Login. ABCBS makes no warranties or representations of any kind, express or implied, nor Please refer to the criteria listed below for genetic testing. You can also visit, Standard Local Prior Authorization Code List, Standard Prior Authorization Requirements, SHBP Precertification Procedure Codes Sheet, SHBP Co-pay/Co-insurance Waiver Medication List. Prior approval for requested services - Arkansas Blue Cross and Blue Shield Prior approval for requested services The primary coverage criteria of certain services must be established through a prior Approval or pre-authorization process before they can be performed. You understand and agree that by making any As healthcare costs go up, health insurance premiums also go up to pay for the services provided. 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. Prior authorization suspension for Anthem Ohio in-network hospital transfers to in-network skilled nursing facilities effective December 20, 2022 to January 15, 2023: Prior authorization suspension - In-network hospital transfers to In-network SNFs . March 2023 Anthem Provider News - Georgia, February 2023 Anthem Provider News - Georgia, New ID cards for Anthem Blue Cross and Blue Shield members - Georgia, Telephonic-only care allowance extended through April 11, 2023 - Georgia, January 2023 Anthem Provider News - Georgia, prior authorization/precertification form, September 2021 Anthem Provider News - Georgia. Federal Employee Program. Sign in to the appropriate website to complete your request. | Step 7 In Medication / Medical and Dispensing Information, specify the following prescription details: dose/strength, frequency, length of therapy/number of refills, and quantity. CareMore Health is a leading primary care provider that specializes in chronic and complex conditions. Obtaining a prior authorization from Blue Cross of Idaho prevents this frustration. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Once you choose to link to another website, you understand and agree that you have exited this Please note that CVS Caremark administers the pharmacy benefits for the State Health Benefit Plan. Ting Vit | Anthem Blue Cross (Anthem) is available by fax or Interactive Care Reviewer (ICR) 24/7 to accept prior authorization requests. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. You can find the number on the back of your ID card, or you can write to us at the following address: Appeals and Grievance CoordinatorBlue Cross of IdahoPO Box 7408Boise, ID 83707. Complete all member information fields on this form: Complete either the denial or the termination information section. Step 8 In Medication / Medical and Dispensing Information, indicate the administration method and administration location. View requirements for Basic Option, Standard Option and FEP Blue Focus. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Use these lists to identify the member services that require prior authorization. * Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Prior authorization requirements will be added for the following codes: Not all prior authorization requirements are listed here. We look forward to working with you to provide quality services to our members. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at availity.com at anthem.com/medicareprovider > Login. If you choose to access other websites from this website, you agree, as a condition of choosing any such The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization/precertification form at anthem.com/medicareprovider > Providers > Provider Resources > Forms and Guides. This may result in a delay of our determination response. No, the need for emergency services does not require prior authorization. Some procedures may also receive instant approval. View pre-authorization requirements for UMP members. 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., 2023. Typically, we complete this review within two business days, and notify you and your provider of our decision. benefit certificate to determine which services need prior approval. Noncompliance with new requirements may result in denied claims. The CarelonRx member services telephone number is 833-279-0458. Contact 866-773-2884 for authorization regarding treatment.