You may submit all your prior authorizations in one application on Availity.com.

You may already be submitting your prior authorizations through the Availity multi-payer Authorization application — taking advantage of the time savings and speed to care through digital authorization submissions. Beginning in March, you can submit both your physical health and behavioral health prior authorizations through one Authorization application on Availity.com.

You can still access the Interactive Care Reviewer (ICR) to review cases that were submitted through that application. You will also continue to use ICR to submit an appeal or authorization for medical specialty Rx.

Using the Availity Authorization application to submit your behavioral health prior authorizations will not be much different from the process you follow today. You may enjoy more intuitive screens or learn sooner if an authorization is required — but the digital submission process is still the very best way to submit your prior authorization and the fastest way to care for our members.

Training is available

If you aren’t already familiar with Availity Authorization, training is available. Select Availity Authorization Training to enroll for an upcoming live webcast or to access an on-demand recording.

Now, give it a try!

Accessing the Availity for authorization is easy. Ask your organization’s Availity administrator to ensure you have the Authorization role assignment. Without the role assignment, you will not be able to access the Authorization application. Then, log on to Availity.com to access the app through the Patient Registration tab by selecting Authorizations and Referrals.

Now accepting Medicaid and Medicare member claims

As a care provider taking advantage of digital requests for additional information (Digital RFAI), you know it is the most efficient way to send the required documentation to process your Commercial member claims. As of February, you also can receive Digital RFAI notifications for your Medicaid and Medicare member claims.

The process will not change for Medicaid and Medicare member claims. You will still follow the same fast and easy process for our Medicaid and Medicare member claims as you do for your commercial member claims. The only difference is that your Medicaid and Medicare member claims will not pend. Medicaid and Medicare member claims will deny when additional documentation is needed to process the claim.*

Notifications will remain on your dashboard for up to 30 days for pended claims as they do today and 45 days for denied claims. After that, those notifications will move to the history tab of your dashboard.. Submit the documentation at your convenience (most care providers submit documents within seven to 14 days).

Your notifications will continue to arrive on your dashboard each morning, making it convenient to plan your work; no need to check your dashboard throughout the day.

* Claims for providers under pre-payment review will pend for 30 days.

Learn more!

In collaboration with Availity, we’ve developed training for your organization’s administrators about how to update the Medical Attachment registration.:

Availity administrators can use this link to register for live training or to view the training on demand.

For associates who are responsible for sending attachments, we’ve developed an enhanced training session that walks through the Attachments Dashboard and many of the unique features that make it most efficient.

Availity users with the Medical Attachments and Claims Status role assignment can use this link to register for live training, or to view the live training on-demand.

Contact Availity Customer Support at availity.com/Contact-Us or your provider relationship representative if you have any questions.

Not a Digital RFAI care provider?

If you’re not already using the Digital RFAI process and want to take advantage of faster claims processing, participation is easy.

We are committed to finding solutions that help our care provider partners offer quality services to our members.

Effective for dates of service on and after May 1, 2024, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of several ways:

• Access the ProviderPortal_SM directly at providerportal.com:
• Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
• Access via Availity.com.

If you have questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

With your help, we can continually build towards a future of shared success.

As part of our ongoing quality improvement efforts, we will be implementing a new Genetic Testing (GT) claim to authorization match enhancement that will ensure GT panels billed have a corresponding authorization. This enhanced match logic will be effective by May 1, 2024. Labs that bill panels with codes in excess of what has been authorized may receive a full claim denial. The goal of this enhanced match logic is to ensure tests performed are authorized and meet medical necessity requirements.

Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s).  The medical code(s) listed below will require PA for Anthem Blue Cross and Blue Shield 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 precertification 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):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call the number on the back of their patient’s member ID card for Provider Services.

Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Medicare 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 precertification 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):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call the number on the back of their patient’s member ID card .for assistance with PA requirements.

Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Medicare 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 precertification 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):

Not all PA requirements are listed here. Detailed PA requirements are available to providers on anthem.com/medicareprovider on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call the number on the back of their patient’s member ID card .for assistance with PA requirements.

Beginning with dates of service on or after May 1, 2024, Anthem will implement a new reimbursement policy titled Modifier Usage — Facility based on the code-set combinations submitted with the correct modifiers. This reimbursement policy identifies the following three different types of facility modifiers:

• Reimbursement modifiers affect payment and denote circumstances when an increase or reduction is appropriate for the service provided. 
• Informational modifiers impacting reimbursement determine if the service provided will be reimbursed or denied. 
• Informational modifiers not impacting reimbursement are used for documentation purposes. 

The Related Coding section of the policy includes a Facility Modifier code list which identifies the modifier, the modifier description, and any related reimbursement policies. The Facility Modifier code list also includes six modifiers that do not have associated reimbursement policies. These modifiers indicate a reduced service or different equipment was used for the service. These modifiers will result in a reduction when billed on a facility claim. 

For specific policy details, visit the reimbursement policy page at anthem.com.

Beginning with dates of service on or after April 1, 2024, Anthem will not reimburse for the following when billed on a UB-04:

• Consultation CPT^® codes 99242–99245, 99251–99255
• Prolonged Services codes 99354–99359, 99415–99417 and G2212

For appropriate billing guidelines of Consultation and Prolonged Services CPT codes, please refer to the corresponding professional Reimbursement Policies:

• Prolonged Services
• Consultation Services

 For specific policy details, visit the reimbursement policy page at anthem.com.

As previously communicated, Anthem developed a policy requiring facilities to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through CVS Specialty Pharmacy.

Updates

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy medications will be removed from the Designated Medical Specialty Pharmacy Drug List:

To access the current Designated Medical Specialty Pharmacy Drug List, please visit anthem.com/provider, select Providers, select Forms and Guides (under the Provider Resources column), select your state, scroll down, and select Pharmacy in the Category drop down. The Designated Medical Specialty Pharmacy Drug List may be updated periodically by Anthem.

If you have questions or would like to discuss the terms and conditions for providing certain specialty medications, please contact your contract manager with Anthem. Thank you for your continued participation in the Anthem networks and for the services you provide to our members. Beyond simply signing a contract, care providers are part of a genuine collaboration aimed at improving the lives of real people.

Specialty pharmacy updates for Anthem are listed below

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Anthem’s Medical Specialty Drug Review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., a separate company.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

Prior authorization updates

Update: In the May 2023 edition of Provider News, we announced prior authorization for Adstiladrin will be effective August 2023. Review of Adstiladrin is managed by Carelon Medical Benefits Management.

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our prior authorization review process.

Access our Clinical Criteria to view the complete information for these prior authorization updates.

* Oncology use is managed by Carelon Medical Benefits Management.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Quantity limit updates

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy codes from current or new Clinical Criteria documents will be included in our quantity limit review process.

Access our Clinical Criteria to view the complete information for these quantity limit updates.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

Effective for dates of service on and after May 1, 2024, the specialty Medicare Part B drugs listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines (including definitions and specific contract provisions/exclusions), take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.