Virginia
Provider Communications

Anthem Blue Cross and Blue Shield local precertification change in Virginia for PPO

Dec 30, 2022 • Administrative

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
MED.00013	Parenteral Antibiotics for the Treatment of Lyme Disease	J0456	April 1, 2023
MED.00013	Parenteral Antibiotics for the Treatment of Lyme Disease	J0696	April 1, 2023
MED.00013	Parenteral Antibiotics for the Treatment of Lyme Disease	J0698	April 1, 2023
MED.00013	Parenteral Antibiotics for the Treatment of Lyme Disease	J2540	April 1, 2023
MED.00013	Parenteral Antibiotics for the Treatment of Lyme Disease	S9494	April 1, 2023
MED.00013	Parenteral Antibiotics for the Treatment of Lyme Disease	S9497	April 1, 2023
MED.00013	Parenteral Antibiotics for the Treatment of Lyme Disease	S9504	April 1, 2023

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

Featured In:
January 2023 Anthem Provider News - Virginia

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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), which underwrites or administers the PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation (Compcare) underwrites or administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem websites constitutes your agreement with our Terms of Use.

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