Policy Updates Prior AuthorizationMedicaidJune 17, 2024

Prior authorization requirement changes

Effective August 1, 2024

Effective August 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicaid members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions and 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

81247

G6PD (glucose-6-phosphate dehydrogenase) (hemolytic anemia, jaundice), gene analysis; common variant(s) (A, A-)

81249

G6PD (glucose-6-phosphate dehydrogenase) (hemolytic anemia, jaundice), gene analysis; full gene sequence

81307

PALB2 (partner and localizer of BRCA2) (breast and pancreatic cancer) gene analysis; full gene sequence

81336

SMN1 (survival of motor neuron 1, telomeric) (spinal muscular atrophy) gene analysis; full gene sequence

81405

Molecular Pathology Procedure Level 6

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

  • Web: Log on to Availity.com.
  • Fax: 800-964-3627
  • Phone: 855-661-2028

Not all PA requirements are listed here. Detailed PA requirements are available to providers on our provider website or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 855-661-2028 for assistance with PA requirements.

UM AROW A2024M1372

Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: July 2024 Provider Newsletter