Members should discuss the information in the medical policies with their treating health care professionals. Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. 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). The Precertification Lookup Tool will let you know if clinical edits apply, information such as the medical necessity criteria used in making the authorization decision, and if a vendor is used -- without the need to make a phone call. We update the Code List to conform to the most recent publications of CPT and HCPCS . Llame a nuestro nmero de Servicio de Atencin al Cliente (TTY: 711). Please note that services listed as requiring precertification may not be covered benefits for a member. Select a State Policies, Guidelines & Manuals We're committed to supporting you in providing quality care and services to the members in our network. In Connecticut: Anthem Health Plans, Inc. You can also visit bcbs.com to find resources for other states. Please verify benefit coverage prior to rendering services. Medical technology is constantly evolving and clinical UM guidelines are subject to change without notice. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Choose your location to get started. Line of Business: Hoosier Care Connect, Anthem Blue Cross and Blue Shield Member site. Medical technology is constantly evolving and these medical policies are subject to change without notice, although we will use good faith efforts to provide advance notice of changes that could have a negative impact on benefits. We offer deep discounts and one of the largest dental networks in the nation, along with ways to customize our plans for total flexibility. We currently don't offer resources in your area, but you can select an option below to see information for that state. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross and Blue Shield Association. Access to the information does not require an Availity role assignment, tax ID or NPI. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Use the Precertification Lookup Tool accessed through Payer Spaces in Availity. We are also licensed to use MCG guidelines to guide utilization management decisions. We look forward to working with you to provide quality service for our members. Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use. There are several factors that impact whether a service or procedure is covered under a members benefit plan. In Indiana: Anthem Insurance Companies, Inc. The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom we have no control or right of control. We currently don't offer resources in your area, but you can select an option below to see information for that state. Inpatient services and non-participating providers always require prior authorization. This tool is for outpatient services only. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Use our app, Sydney Health, to start a Live Chat. Available for iOS and Android devices. Other ways to access: If you are currently accessing the Pre-certification / Pre-Authorization Requirements list through your health plans public website, this option is still available for you. 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. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. With features like these, its no surprise: Conviction is just one of more than 130 such criminal cases involving 80 million A federal jury convicted a Colorado physician Jan. 13 for misappropriating about 250000 from two separate COVID19 relie Can depression increase the risk of heart disease In recent years scientists have attempted to establish a link between depression and heart disease. Please verify benefit coverage prior to rendering services. It may not display this or other websites correctly. Members should contact their local customer service representative for specific coverage information. Clinical UM guidelines can be highly technical and complex and are provided here for informational purposes. Prior Authorization Code Lookup Find out if prior authorization from Highmark Health Options is required for medical procedures and services. 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. Your online account is a powerful tool for managing every aspect of your health insurance plan. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. In Indiana: Anthem Insurance Companies, Inc. In Maine: Anthem Health Plans of Maine, Inc. February 2023 Anthem Provider News - Nevada, New ID cards for Anthem Blue Cross and Blue Shield members - Nevada, Telephonic-only care allowance extended through April 11, 2023 - Nevada, January 2020 Anthem Provider News and Important Updates - Nevada. We currently don't offer resources in your area, but you can select an option below to see information for that state. 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. Medicare and some payers may allow providers of different specialties to report initial hospital services and require the admitting/supervising provider to append modifier AI. 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. out of your benefits, find the best healthcare, and stay healthy. 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. Talk to a health plan consultant: 833-828-6962 (TTY: 711) Mon-Fri, 8 a.m. to 8 p.m. ET/CT, 7 a.m. to 7 p.m. MT/PT. Directions. The resources on this page are specific to your state. Employers can choose from a variety of medical, pharmacy, dental, vision, life, and disability plans. American Hospital Association ("AHA"), Jury Convicts Physician for Misappropriating $250K From COVID-19 Relief, REVCON Wrap-up: Mastering the Revenue Cycle, OIG Audit Prompts ASPR to Improve Its Oversight of HPP, Check Out All the New Codes for Reporting Services and Supplies to Medicare, Keyword database enhanced with medical acronyms and terminology, Default settings to lock in your preference for code-centered or range pages, Code Constructor to narrow down your code options one clickable range at a time, Lay terms and CPT code update information, An expanded index by service eases looking for a procedure or service. We look forward to working with you to provide quality services to our members. For a better experience, please enable JavaScript in your browser before proceeding. We look forward to working with you to provide quality service for our members. The notices state an overpayment exists and Anthem is requesting a refund. Type a Current Procedural Terminology, or CPT, code or a Healthcare Common Procedure Coding System, or HCPCS, code in the space below to get started. I didn't think Anthem was accepting codes 99251-99255, this maybe for the Medicare Products Only. 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. Independent licensees of the Blue Cross Association. Understand your care options ahead of time so you can save time and money. The resources for our providers may differ between states. In Ohio: Community Insurance Company. You can also visit bcbs.com to find resources for other states. For discharge from an inpatient stay on a different date of service than the admission, see 99238-99239. To get started, select the state you live in. As the nations second largest health plan-owned company, Anthem Behavioral Health provides choice, innovation and access. Join us for a live webinar demonstration and learn how these enhancements will improve member information return. We currently don't offer resources in your area, but you can select an option below to see information for that state. Providers: Select Hoosier Care Connect in the Line of Business field whenever applicable. Please verify benefit coverage prior to rendering services. 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 authorizations are required for: All non-par providers. Medicare Complaints, Grievances & Appeals. Review medical and pharmacy benefits for up to three years. We currently don't offer resources in your area, but you can select an option below to see information for that state. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, nor is it an explanation of benefits. The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom we have no control or right of control. These guidelines do not constitute medical advice or medical care. You must log in or register to reply here. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. 2005 - 2023 copyright of Anthem Insurance Companies, Inc. If you arent registered to use Availity, signing up is easy and 100% secure. Members should discuss the information in the clinical UM guideline with their treating health care providers. Type at least three letters and we will start finding suggestions for you. Precertification lookup tool | Anthem Precertification lookup tool Please verify benefit coverage prior to rendering services. We offer affordable health, dental, and vision coverage to fit your budget. Additional medical policies may be developed from time to time and some may be withdrawn from use. Or Understand your care options ahead of time so you can save time and money. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Our resources vary by state. If a prior authorization (PA) is required (indicates "yes" or "no") If there are PA conditions; If the service is a covered benefit (indicates "covered" or "not covered") We have developed clinical UM guidelines that serve as one of the sets of guidelines for coverage decisions. Enter a Current Procedural Terminology (CPT) code in the space below to get started. Our NCCI Edit tool will help you prevent denials from Medicares National Correct Coding Initiative edits. 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. After hours, verify member eligibility by calling the 24/7 NurseLine at 1-800-224-0336. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Weve got the latest advice, tips, and news to help you get the mostout of your benefits, find the best healthcare, and stay healthy. If this is your first visit, be sure to check out the. In Kentucky: Anthem Health Plans of Kentucky, Inc. Provider Policies, Guidelines and Manuals | Anthem.com Find information that's tailored for you. Explore our resources. Find drug lists, pharmacy program information, and provider resources. We currently don't offer resources in your area, but you can select an option below to see information for that state. Use of the Anthem websites constitutes your agreement with our Terms of Use. Inpatient services and non-participating providers always require prior authorization. These learning opportunities will assist you in administering your patients health plan and provide you with the knowledge to best assist our members. Future updates regarding COVID-19 will appear in the monthly Provider News publication. Our resources vary by state. Your browser is not supported. Lets make healthy happen. * Services may be listed as requiring precertification (prior authorization) that may not be covered benefits for a particular member. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. Taking time for routine mammograms is an important part of staying healthy. Independent licensees of the Blue Cross and Blue Shield Association. In Maine: Anthem Health Plans of Maine, Inc. The MCG guidelines we are licensed to use include ((1) Inpatient & Surgical Care (ISC), (2) General Recovery Care (GRG), (3) Recovery Facility Care (RFC), (4) Chronic Care (CC) and (5) Behavioral Health Care Guidelines (BHG). Medical policies can be highly technical and complex and are provided here for informational purposes. Apr 1, 2022 It looks like you're outside the United States. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. We offer flexible group insurance plans for any size business. If your state isn't listed, check out bcbs.com to find coverage in your area. There is no cost for our providers to register or to use any of the digital applications. Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular clinical UM guideline. Prior Authorization Lookup. Your dashboard may experience future loading problems if not resolved. Click Submit. Select Your State Call Provider Services at 1-800-454-3730 (TTY 711) After hours, verify member eligibility by calling the 24/7 Nurse HelpLine at 1-800-600-4441. For medical policies for other Blue plans, use the Medical Policy & Pre-Cert/Pre-Auth Router. Choose your state below so that we can provide you with the most relevant information. Benefit Lookup by Procedure Code Webinar Tuesday, April 12, 2022 11 to 11:45 a.m. We look forward to working with you to provide quality service for our members. 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. While the clinical UM guidelines developed by us are published on this web site, the licensed standard and customized MCG guidelines are proprietary to MCG and are not published on the Internet site. Inpatient services and non-participating Anthem HealthKeepers Plus providers always require prior authorization. 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. Use our library of self-paced courses and instructor-led training sessions, available 24/7 at no cost. The resources for our providers may differ between states. Easy access CPT Assistant archives, published by the AMA, and the AHA Coding Clinic. Use the Prior Authorization tool within Availity. Once youve accessed the Precertification Lookup Tool, choose a line of business from the menu selection offered, and then type the CPT/HCPCS code or a code description to determine if a prior authorization is required. 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. Explore programs available in your state. Please note: This tool is for outpatient services only. Inpatient services and non-participating providers always require prior authorization. You can also visit bcbs.com to find resources for other states It looks like you're outside the United States. Additionally, some benefit plans administered by the Plan such as some self-funded employer plans or governmental plans, may not utilize the Plans medical policy. If youre concerned about losing coverage, we can connect you to the right options for you and your family. Choose your state below so that we can provide you with the most relevant information. Choose your location to get started. 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. Most Recently our office has been sent several recoupment notification from Anthem Blue Cross Blue Shield. It looks like you're in . Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. This tool is for outpatient services only. 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. Plus, you may qualify for financial help to lower your health coverage costs. Out-of-state providers. State & Federal / Medicaid. It looks like you're outside the United States. 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. Audit reveals crisis standards of care fell short during pandemic. Pay outstanding doctor bills and track online or in-person payments. Codify by AAPC helps you quickly and accurately select the CPT codes you need to keep your claims on track. Select a State Policies & Guidelines Medical Policies & Clinical UM Guidelines There are several factors that impact whether a service or procedure is covered under a member's benefit plan. The tool will tell you if that service needs . Navigate to the Precertification Lookup Tool on the Availity Portal by selecting either 1) Payer Spaces or 2) Patient Registration from Availitys homepage. Benefit Lookup by Procedure Code Webinar Tuesday, April 12, 2022 11 to 11:45 a.m. Large Group If you are unsure or have any questions, please be sure to check member eligibility and benefit coverage before proceeding with any authorization requests or services by contacting Provider Services at 800-901-0020. Our resources vary by state. If you would like to request a hard copy of an individual clinical UM guideline or MCG guideline, please contact the member's health plan at the number on the back of their identification card. Enter one or more keyword (s) for desired policy or topic. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. Do not sell or share my personal information. If you would like to request a hard copy of an individual medical policy, please contact the member's health plan at the number on the back of their identification card. In Kentucky: Anthem Health Plans of Kentucky, Inc. This tool does not reflect benefits coverage* nor does it include an exhaustive listing of all non-covered services (i.e., experimental procedures, cosmetic surgery, etc.) Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. 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. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. These documents are available to you as a reference when interpreting claim decisions. Select Auth/Referral Inquiry or Authorizations. There is no cost for our providers to register or to use any of the digital applications. All other available Medical Policy documents are published by policy/topic title. Price a medication, find a pharmacy,order auto refills, and more. Checking the CMS ordering/referring provider downloadable report containing the NPI, first name, and last name of providers enrolled in PECOS. With Codify by AAPC cross-reference tools, you can check common code pairings. 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. We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions.