Medicaid Managed CareNovember 12, 2024
Prior authorization requirement changes
Effective January 1, 2025, prior authorization (PA) requirements will change for the following codes. The medical codes listed below will require PA by Anthem 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 |
0468U | Hepatology (nonalcoholic steatohepatitis [NASH]), miR-34a-5p, alpha 2-macroglobulin, YKL40, HbA1c, serum and whole blood, algorithm reported as a single score for NASH activity and fibrosis |
E0482 | Cough stimulating device, alternating positive and negative airway pressure |
J0687 | Injection, cefazolin sodium (WG Critical Care), not therapeutically equivalent to J0690, 500 mg |
J0688 | Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg |
J0689 | Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg |
J0744 | Injection, ciprofloxacin for intravenous infusion, 200 mg |
J2183 | Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mg |
J2184 | Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mg |
J2281 | Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mg |
To request PA, you may use one of the following methods:
- Web: Once logged in to Availity Essentials at https://Availity.com.
- Fax:
- 877-643-0672 for physical health
- 866-577-2183 for behavioral health
- Phone: 800-601-9935
Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://providers.anthem.com/oh on the Resources tab or for contracted providers by accessing https://Availity.com. Providers may also call Provider Services at 844-912-1226 for assistance with PA requirements.
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Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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