Virginia
Provider Communications
Anthem Blue Cross and Blue Shield local precertification change in Virginia for HMO
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 Essentials* 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 |
|
LAB.00033 |
Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer |
0228U |
May 1, 2023 |
|
RAD.00064 |
Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT) |
0331T |
May 1, 2023 |
|
RAD.00064 |
Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT) |
0332T |
May 1, 2023 |
|
SURG.00121 |
Transcatheter Heart Valve Procedures |
0646T |
May 1, 2023 |
|
SURG.00010 |
Treatments for Urinary Incontinence |
0672T |
May 1, 2023 |
Featured In:
February 2023 Anthem Provider News - Virginia