Policy Updates Prior AuthorizationMedicaidDecember 13, 2023

Prior authorization requirement changes effective April 1, 2024

Effective April 1, 2024, prior authorization (PA) requirements will change for the following code. The medical code listed below will require PA by Anthem Blue Cross for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Code

Description

J1411

Injection, etranacogene dezaparvovec-drlb, per therapeutic dose (Hemgenix)

To request PA, you may use one of the following methods:

  • Web: Availity Essentials platform at Availity.com.
  • Fax: 800-754-4708
  • Phone: Medi-Cal: 888-831-2246
                MRMIP: 877-273-4193

Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://providers.anthem.com/ca on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call one of the following numbers for Provider Services for assistance with PA requirements:

  • Outside of Los Angeles County: 800-407-4627
  • Within Los Angeles County: 888-285-7801

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CABC-CD-039438-23-CPN38396

PUBLICATIONS: January 2024 Provider Newsletter