The following services will be added to precertification for the effective dates listed below.

 

Precertification responsibility: The ordering or rendering provider of service is responsible for completing the precertification process.

 

HMO plans: Services that require precertification will be denied if rendered without the appropriate precertification for in-network providers. HMO members may not have benefits for non-emergency services rendered outside of the network and are subject to review and may be denied.

 

PPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement.

 

EPO plans: Precertification for services requiring prior approval is highly recommended. If not completed in advance, a pre-payment review of the claim will occur and may result in a denial of claim reimbursement. No out-of-network benefit is available with the exception of ER/urgent care and authorized services.

 

Requesting precertification with the Virginia plan

To obtain precertification, providers can access Availity* at www.availity.com or call the Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

 

Criteria

Criteria description

Codes

Effective date

MED.00013

Parenteral Antibiotics for the Treatment of Lyme Disease

96365

April 1, 2023

MED.00013

Parenteral Antibiotics for the Treatment of Lyme Disease

96372

April 1, 2023

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.


VABCBS-CM-012058-22



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January 2023 Anthem Provider News - Virginia