Important COVID-19 update: Prior authorization and other policy adjustments (Updated September 10, 2021)
Please note that the following information applies to Anthem’s Commercial health plans. Please review the Medicare and Medicaid specific sites noted below for details about these plans.
Commercial: Provider News Home
COVID-19 Update: Anthem updates guidance on prior authorization requirements and other policy adjustments in response to unprecedented demands on health care providers
Anthem recognizes the intense demands facing doctors, hospitals and health care providers in the face of the COVID-19 crisis. Unless otherwise required under State and Federal mandates, Anthem health plans are making adjustments to assist providers in caring for members. These adjustments apply to members of all lines of business except as noted below, including self-insured plan members and in-network and out-of-network providers, where permissible.
Medicare adjustments and suspensions may have different timeframes or changes where required by federal law.
Where permissible, these guidelines apply to Federal Employee Plan (FEP®) members. For the most up-to-date information about the changes FEP is making, go to https://www.fepblue.org/coronavirus.
Prior authorization requirements were suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective December 21, 2020 through January 31, 2021. These adjustments applied for our fully-insured and self-funded employer, individual, Medicare and Medicaid plan members receiving care from in-network providers. While prior authorization was not required, we required notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.
Consistent with the Colorado Governor’s Executive Order issued on November 23, 2020, if a Colorado facility was determined by CDPHE to be at capacity, a person transferred to another facility between November 23, 2020, and December 23, 2020, under the terms of the executive order were considered by Anthem as having an emergency medical condition. This means the transfer and admission at the receiving facility was not subject to prior authorization requirements. It is important to remember that under the executive order, providers are required to follow the protections against balance billing and identify those patients that were transferred or received during this period. Any waiver of prior authorization is not a guarantee of payment. If the claim or patient is not properly identified, or if the claim is for a transfer outside the scope of the emergency order, the claim may deny for lack of benefit or lack of prior authorization. It is also important to remember that not all plans are subject to the order and if the patient’s identification card does not have “CO-DOI” on it, the patient’s plan may have different requirements.
Inpatient and respiratory care
Prior authorization requirements are suspended for patient transfers from acute IP hospitals to skilled nursing facilities effective September 10, 2021, through September 24, 2021. These adjustments applied for our fully-insured and self-funded employer, individual and Medicare plan members receiving care from in-network providers. While prior authorization was not required, we required notification of the admission via the usual channels and clinical records on day two of admission to aid in our members’ care coordination and management. Anthem reserves the right to audit patient transfers.
Prior authorization requirements were suspended for patient transfers through May 30, 2020. Prior authorization was waived for patient transfers from acute IP hospitals to skilled nursing facilities, rehabilitation hospitals, long-term acute care hospitals, and Behavioral Health residential/intensive outpatient/partial hospitalization programs, and to home health including ground transport in support of those transfers. Anthem will continue to waive prior authorization for patients with a COVID-19 diagnosis to the extent required by applicable law. Although prior authorization is not required, Anthem requests voluntary notification via the usual channels to aid in our members’ care coordination and management.
Extended the length of time a prior authorization issued on or before May 30, 2020, was in effect for elective inpatient and outpatient procedures to 180 days. This helped prevent the need for additional outreach to Anthem to adjust the date of service covered by the authorization.
Concurrent review for discharge planning will continue unless required to change by federal or state directive.
Prior authorization requirements are suspended for COVD-19 Durable Medical Equipment including oxygen supplies, respiratory devices, continuous positive airway pressure (CPAP) devices, non-invasive ventilators, and multi-function ventilators for patients who need these devices for COVID-19 treatment, along with the requirement for authorization to exceed quantity limits on gloves and masks.
Respiratory services for acute treatment of COVID-19 will be covered. Prior authorization requirements are suspended where previously required.
Laboratory tests for COVID-19 at both in-network and out-of-network laboratories will be covered with no cost sharing for members.
Claims audits, retrospective review, peer-to-peer review and policy changes
Anthem will adjust the way we handle and monitor claims to ease administrative demands on providers:
Hospital claims audits requiring additional clinical documentation were limited through June 24, 2020, though Anthem reserves the right to conduct retrospective reviews on these findings with expanded lookback recovery periods for all lines of business except Medicare. To assist providers, Anthem can offer electronic submission of clinical documents through the provider portal.
Retrospective utilization management review was suspended through June 24, 2020, and Anthem reserves the right to conduct retrospective utilization management review of these claims when this period ends and adjust claims as required.
Suspend peer-to-peer reviews through June 24, 2020, except where required pre-denial per operational workflow or where required by State during this time period for all lines of business except Medicare.
Our Special Investigation programs targeting provider fraud will continue, as well as other program integrity functions that help ensure payment accuracy.
Otherwise, Anthem will continue to administer claims adjudication and payment in line with our benefit plans and state and federal regulations, including claims denials where applicable. Our timely filing requirements remain in place, but Anthem is aware of limitations and heightened demands that may hinder prompt claims submission.
Through June 24, 2020, Anthem processed provider credentialing within the standard 15-18 days even if we were unable to verify provider application data due to disruptions to licensing boards and other agencies. We will verify this information when available.
If Anthem finds that a practitioner fails to meet our minimum criteria because of sanctions, disciplinary action etc., we will follow the normal process of sending these applications to committee review, which will add to the expected 15-18 day average timeline. We are monitoring and will comply with state and federal directives regarding provider credentialing.
Please note that the above information applies to Anthem’s Commercial health plans. Please review the Medicare and Medicaid specific sites noted below for future administrative or policy adjustments we may make in response to the COVID-19 pandemic.
Commercial: Provider News Home
COVID-19 Information - Colorado