Step 1 At the top of the form, supply the plan/medical group name, plan/medical group phone number, and plan/medical group fax number. You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association. View medication policies and pre-authorization requirements. 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. | ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. If yes, provide the medication name, dosage, duration of therapy, and outcome. Anthem partners with health care professionals to close gaps in care and improve members overall heath. Inpatient services and nonparticipating providers always require prior authorization. Also, specify any allergies and give the name and phone number of the patients authorized representative (if applicable). . 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. In Indiana: Anthem Insurance Companies, Inc. 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. Find care, claims & more with our new app. Do not sell or share my personal information. Non-individual members Use Availity to submit prior authorizations and check codes. A new prior | Kreyl Ayisyen | Please refer to Availity Essentials portal, Arkansas Blue Cross Coverage Policy or the members Copyright 2001-2023 Arkansas Blue Cross and Blue Shield. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. You can also refer to the provider manual for information about services that require prior authorization. of merchantability or fitness for a particular purpose, nor of non-infringement, with regard to the content If your state isn't listed, check out bcbs.com to find coverage in your area. If we deny your request for coverage or you have questions regarding your prior authorization, please call Blue Cross of Idahos Customer Service. You further agree that ABCBS and its benefit certificate to determine which services need prior approval. 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. Tagalog | In the case of a medical emergency, you do not need prior authorization to receive care. In Connecticut: Anthem Health Plans, Inc. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. 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. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. | An Anthem(Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patients prescription cost. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at availity.com at anthem.com/medicareprovider > Login. To stay covered, Medicaid members will need to take action. 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. Deutsch | 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. website. The Internet Explorer 11 browser application will be retired and go out of support on June 15, 2022. Located in neighborhoods all over the country, CareMore Health Care Centers combine a variety of different specialty services under one roof. More prior authorization resources Sign in to Availity 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. of all such websites. Select Auth/Referral Inquiry or Authorizations. Anthem Blue Cross Blue Shield: Health Insurance, Medicare & More Stay Covered When Medicaid Renewals Begin Medicaid renewals will start again soon. or operation of any other website to which you may link from this website. Type at least three letters and we will start finding suggestions for you. Step 10 On page 2 (1), select yes or no to indicate whether the patient has tried other medications for their condition. 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. In Connecticut: Anthem Health Plans, Inc. 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. Oromoo | Franais | ), 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. | Please verify benefit coverage prior to rendering services. We look forward to working with you to provide quality services to our members. Anthem is a registered trademark of Anthem Insurance Companies, Inc. | Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Medi-Cal Managed Care and Major Risk Medical Insurance Program Provider Manual. Learn more about electronic authorization. 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 We want you to receive the best care at the right time and place. Our team of licensed physicians, registered nurses, or pharmacy technicians receive and review all prior authorization requests. 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. If you choose to access other websites from this website, you agree, as a condition of choosing any such We currently don't offer resources in your area, but you can select an option below to see information for that state. In some cases, we require more information and will request additional records so we can make a fully informed decision. February 2023 Anthem Provider News - Ohio, New ID cards for Anthem Blue Cross and Blue Shield members - Ohio, Telephonic-only care allowance extended through April 11, 2023 - Ohio, C1764 Event recorder, cardiac (implantable), E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized, E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, 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, L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each, L3310 Lift, elevation, heel and sole, neoprene, per inch, L3332 Lift, elevation, inside shoe, tapered, up to one-half inch, L3580 Ortho shoe add instep Velcro closure, L3610 Transfer of an orthosis from one shoe to another, caliper plate, new, L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing, L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new, L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified, L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf, L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf, L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf, L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf, L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise, L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type, L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf, L3913 HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment, L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
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