Prior authorization requirement changes effective November 1, 2022

Medicaid

Effective November 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Anthem Blue Cross and Blue Shield Healthcare Solutions. Federal and state law, as well as state contract language, and CMS 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.

 

PA requirements will be added to the following:

• 0214U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O.
• 0215U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O.
• L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device.

 

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

• Availity:* Once logged in to Availity.com, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry, as appropriate.
• Fax: 800-964-3627
• Phone: 844-396-2330

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/nv. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 844-396-2330 for assistance with PA requirements.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Healthcare Solutions.
AN-NU-0329-22