Select a State Policies, Guidelines & Manuals We're committed to supporting you in providing quality care and services to the members in our network. Enter a Current Procedural Terminology (CPT) code in the space below to get started. In Kentucky: Anthem Health Plans of Kentucky, Inc. Not connected with or endorsed by the U.S. Government or the federal Medicare program. Members should discuss the information in the medical policies with their treating health care professionals. You also get CPT to ICD-10-CM, CPT to HCPCS, and CPT to Modifier crosswalks. Use our library of self-paced courses and instructor-led training sessions, available 24/7 at no cost. Prior Authorization Code Lookup Find out if prior authorization from Highmark Health Options is required for medical procedures and services. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Keep in mind that determination of coverage under a member's plan does not necessarily ensure reimbursement. Use the Precertification Lookup Tool accessed through Payer Spaces in Availity. We currently don't offer resources in your area, but you can select an option below to see information for that state. CPT guidelines indicate these services are reported only by the admitting/supervising provider; all other providers should report 99231-99233 or 99251-99255. Enter one or more keyword (s) for desired policy or topic. Please verify benefit coverage prior to rendering services. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use. We also have the right to customize MCG guidelines based on determinations by the Medical Policy & Technology Assessment Committee (MPTAC). 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. Future updates regarding COVID-19 will appear in the monthly Provider News publication. Access to the information does not require an Availity role assignment, tax ID or NPI. Were committed to supporting you in providing quality care and services to the members in our network. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. 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, AIM PT/OT/ST Authorization Important Notice, Anthem taps Paul Marchetti to lead companys overall care transformation strategy, Medicare Supplement claim error expected to be resolved by March 31, Medicare Supplement members to receive new ID cards; claims handling for crossover, Medicare Supplement Member ID Card Change Postponed. 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. 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. Medical policy does not constitute plan authorization, nor is it an explanation of benefits. Join us for a live webinar demonstration and learn how these enhancements will improve member information return. Choose your location to get started. Independent licensees of the Blue Cross and Blue Shield Association. 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. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Choose your location to get started. To stay covered, Medicaid members will need to take action. ) refer to your, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity or. Deleted codes and their replacements, if applicable, add context to old or unfamiliar codes. New member? Type at least three letters and well start finding suggestions for you. Plus, you may qualify for financial help to lower your health coverage costs. Inpatient services and non-participating Anthem HealthKeepers Plus providers always require prior authorization. No provider of outpatient services gets paid without reporting the proper CPT codes. 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") Taking time for routine mammograms is an important part of staying healthy. In Maine: Anthem Health Plans of Maine, Inc. You can also visit. We currently don't offer resources in your area, but you can select an option below to see information for that state. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. Employers can choose from a variety of medical, pharmacy, dental, vision, life, and disability plans. If youre concerned about losing coverage, we can connect you to the right options for you and your family. You can also visit bcbs.com to find resources for other 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. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. We look forward to working with you to provide quality services to our members. 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. Access your member ID card from our website or mobile app. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. 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 / Digital Tools, Learn more by attending this live webinar. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. For medical policies for other Blue plans, use the Medical Policy & Pre-Cert/Pre-Auth Router. Find out if a service needs prior authorization. Posted on December 7th, 2021 in Bulletin Board by Kianoush Moradian. Most Recently our office has been sent several recoupment notification from Anthem Blue Cross Blue Shield. Reimbursement Policies. You can access the Precertification Lookup Tool through the Availity Portal. Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022. 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. 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. 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. Provider Medical Policies | Anthem.com Find information that's tailored for you. Please verify benefit coverage prior to rendering services. For subsequent inpatient care, see 99231-99233. 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. In Indiana: Anthem Insurance Companies, Inc. 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. Prior Authorization Lookup. You can also type part of the code's description to search, for example type "tonsil" to find "Removal of tonsils." This tool can be used to check if a prior authorization is required for health care services covered by Blue Cross and Blue Shield of Minnesota commercial health plans, Medicare Advantage and Platinum Blue. Explore programs available in your state. Line of Business: Hoosier Care Connect, Anthem Blue Cross and Blue Shield Member site. It does not reflect benefits coverage, nor does it include an exhaustive listing of all non-covered services (in other words, experimental procedures, cosmetic surgery, etc.). Screening, Brief Intervention, and Referral to Treatment, Early and Periodic Screening, Diagnostic and Treatment, Indiana Medicaid Prior Authorization Requirements List, New Option Available for Indiana Market. 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. Choose your state below so that we can provide you with the most relevant information. Access resources to help health care professionals do what they do bestcare for our members. Our resources vary by state. Your browser is not supported. Checking the CMS ordering/referring provider downloadable report containing the NPI, first name, and last name of providers enrolled in PECOS. Understand your care options ahead of time so you can save time and money. Please update your browser if the service fails to run our website. 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). If your state isn't listed, check out bcbs.com to find coverage in your area. We currently don't offer resources in your area, but you can select an option below to see information for that state. 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. State & Federal / Medicaid. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. The resources for our providers may differ between states. Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular clinical UM guideline. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Start a Live Chat with one of our knowledgeable representatives. The resources for our providers may differ between states. 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. Prior authorization requirements and coverage may vary from standard membership and will be documented in additional information sections. 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. Our NCCI Edit tool will help you prevent denials from Medicares National Correct Coding Initiative edits. 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 are also licensed to use MCG guidelines to guide utilization management decisions. The resources for our providers may differ between states. Prior authorization lookup tool Please verify benefit coverage prior to rendering services. In Maine: Anthem Health Plans of Maine, Inc. Additional medical policies may be developed from time to time and some may be withdrawn from use. A group NPI cannot be used as ordering NPI on a Medicare claim. Prior authorizations are required for: All non-par providers. You are using an out of date browser. The resources for our providers may differ between states. We look forward to working with you to provide quality service for our members. Anthem offers great healthcare options for federal employees and their families. 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. To get started, select the state you live in. Find drug lists, pharmacy program information, and provider resources. Pay outstanding doctor bills and track online or in-person payments. If your state isn't listed, check out bcbs.com to find coverage in your area. It looks like you're outside the United States. Start by logging onto Availity.com and selecting the Register icon at the top of the home screen or use this link to access the registration page. Healthcare Effectiveness Data and Information Set (HEDIS), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Contact will be made by an insurance agent or insurance company. 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 look forward to working with you to provide quality services to our members. This tool is for outpatient services only. Choose your state below so that we can provide you with the most relevant information. Find drug lists, pharmacy program information, and provider resources. 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. With Codify by AAPC cross-reference tools, you can check common code pairings. CPT guidelines indicate these services are reported only by the admitting/supervising provider; all other providers should report 99231-99233 or 99251-99255. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. New member? 711. Here you'll find information on the available plans and their benefits. Provider Policies, Guidelines and Manuals | Anthem.com Find information that's tailored for you. In Connecticut: Anthem Health Plans, Inc. Please Select Your State The resources on this page are specific to your state. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Anthem HealthKeepers Plus, offered by HealthKeepers, Inc., is a health plan that contracts with the Virginia Department of Medical Assistance Services to provide Medicaid benefits to enrollees. Or 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. You can access the Precertification Lookup Tool through the Availity Portal. Medicare Complaints, Grievances & Appeals. Compare plans available in your area and apply today. Easy access CPT Assistant archives, published by the AMA, and the AHA Coding Clinic. These guidelines do not constitute medical advice or medical care. 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. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. E0731 Conductive garment for Tens G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each We want to help physicians, facilities and other health care professionals submit claims accurately. 2005 - 2023 copyright of Anthem Insurance Companies, Inc. We look forward to working with you to provide quality service for our members. 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 resources for our providers may differ between states. These guidelines address the medical necessity of existing, generally accepted services, technologies and drugs. 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. Register now, or download the Sydney Health app to access your benefits, ID card, pharmacy info, and more. ET Register Here Become an Availity user today If you aren't registered to use Availity, signing up is easy and 100% secure. Whether you need to check on a claim, pay a bill, or talk to a representative, you can easily access all your member features. Make your mental health a priority. 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. Choose your location to get started. A clinical UM guideline does not constitute plan authorization, nor is it an explanation of benefits. The COVID19 pandemic and nationwide shutdown that started in March 2020 placed a spotlight on crisis preparedness within the U.S. hea Dont assume the codes youve been using to report drugs and biologicals still apply. We look forward to working with you to provide quality service for our members. Keep patients healthy and safe by becoming familiar with the tools and strategies useful in protecting yourself and our members against contagious illnesses. If you arent registered to use Availity, signing up is easy and 100% secure. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Members should contact their local customer service representative for specific coverage information. Our resources vary by state. JavaScript is disabled. We currently don't offer resources in your area, but you can select an option below to see information for that state. If this is your first visit, be sure to check out the. We have developed clinical UM guidelines that serve as one of the sets of guidelines for coverage decisions. 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. 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've provided the following resources to help you understand Anthem's prior authorization process and obtain authorization for your patients when it's required. This tool is for outpatient services only. You must log in or register to reply here. Available for iOS and Android devices. It looks like you're outside the United States. Price a medication, find a pharmacy,order auto refills, and more. Select Auth/Referral Inquiry or Authorizations. Large Group The clinical UM guidelines published on this web site represent the clinical UM guidelines currently available to all health plans throughout our enterprise. 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. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Our call to Anthem resulted in a general statement basically use a different code. If your state isn't listed, check out bcbs.com to find coverage in your area. Please verify benefit coverage prior to rendering services. Please note: This tool is for outpatient services only. 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. Inpatient services and nonparticipating providers always require prior authorization. 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. It looks like you're in . Use of the Anthem websites constitutes your agreement with our Terms of Use. 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. 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. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Medical technology is constantly evolving and clinical UM guidelines are subject to change without notice. Find a Medicare plan that fits your healthcare needs and your budget. To help facilitate a seamless transition in understanding Cardinal Care program changes as it relates to authorization requirements, the below guidance is being provided. 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. Our resources vary by state. Our resources vary by state. We have developed medical policies that serve as one of the sets of guidelines for coverage decisions. Members should contact their local customer service representative for specific coverage information. We look forward to working with you to provide quality service for our members. Your browser is not supported. Its proven that a diagnosis of heart disease or ex Healthcare business professionals from around the world came together at REVCON a virtual conference by AAPC Feb. 78 to learn how to optimize their healthcare revenue cycle from experts in the field. Interested in joining our provider network? Our resources vary by state. Audit reveals crisis standards of care fell short during pandemic. Our small business plans offer a full range of health insurance options for groups with 2 to 50 or 100 employees, depending on your state. 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. The notices state an overpayment exists and Anthem is requesting a refund. Your browser is not supported. Independent licensees of the Blue Cross and Blue Shield Association. Your dashboard may experience future loading problems if not resolved. 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. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Please note that services listed as requiring precertification may not be covered benefits for a member. ET. 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. It looks like you're in . Health equity means that everyone has the chance to be their healthiest. Select Auth/Referral Inquiry or Authorizations. Directions. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. Please verify benefit coverage prior to rendering services. 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. 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. Call our Customer Service number, (TTY: 711). For patients admitted and discharged from observation or inpatient status on the same date, see 99234-99236. There are several factors that impact whether a service or procedure is covered under a members benefit plan. The medical policies generally apply to all of the Plans fully-insured benefits plans, although some local variations may exist. We offer deep discounts and one of the largest dental networks in the nation, along with ways to customize our plans for total flexibility. Codify by AAPC helps you quickly and accurately select the CPT codes you need to keep your claims on track. 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). We offer affordable health, dental, and vision coverage to fit your budget. Home Employer Federal Employees Blue Cross And Blue Shield Service Benefit Plans Medical Plans registered for member area and forum access, https://www11.anthem.com/provider/noapplication/f0/s0/t0/pw_g280336.pdf?refer=ahpmedprovider&state=mo. This page outlines the basis for reimbursement if the service is covered by an Anthem member's benefit plan. These documents are available to you as a reference when interpreting claim decisions. Please verify benefit coverage prior to rendering services. Our research shows that subscribers using Codify by AAPC are 33% more productive. 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. We currently don't offer resources in your area, but you can select an option below to see information for that state. It may not display this or other websites correctly. Type at least three letters and we will start finding suggestions for you. As the nation's second largest health plan-owned company, Anthem Behavioral Health provides choice, innovation and access. CHPW's Procedure Code Lookup Tool lets you search for services by procedure code and line of business to determine:. 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. 2020 copyright of Anthem Insurance Companies, Inc. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Inpatient services and non-participating Anthem HealthKeepers Plus providers always require prior authorization. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. Current Procedural Terminology, more commonly known as CPT, refers to a medical code set created and maintained by the American Medical Association and used by physicians, allied health professionals, nonphysician practitioners, hospitals, outpatient facilities, and laboratories to represent the services and procedures they perform. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the clinical UM guidelines. Use the Prior Authorization tool within Availity OR. Where is the Precertification Lookup Tool located on Availity? Treating health care providers are solely responsible for diagnosis, treatment and medical advice. These learning opportunities will assist you in administering your patients health plan and provide you with the knowledge to best assist our members. Inpatient services and non-participating providers always require prior authorization. The medical policies do not constitute medical advice or medical care. In Ohio: Community Insurance Company. Choose your location to get started. We offer low-cost coverage for children, adults, and families who qualify for state-sponsored programs.