Prior authorization requirement changes for medical codes 0205U, 0209U, and 0218U effective September 1, 2021
Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Effective September 1, 2021, prior authorization (PA) requirements will change for 0205U, 0209U, and 0218U. The medical codes listed below will require PA from HealthKeepers, Inc. for our members. 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. Noncompliance with new requirements may result in denied claims.
PA requirements will be added to the following:
Utilization Management Authorization Rule Operations Workgroup item 1327 (UM AROW 1327)
- 0205U — ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negative for neovascular age-related macular-degeneration risk associated with zinc supplements
- 0209U — cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities
- 0218U — neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or saliva, identification and characterization of genetic variants
To request PA, you may use one of the following methods:
- Web: https://providers.anthem.com/va
- Fax: 800-964-3627
- Phone: 800-901-0020
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool through the Availity* Portal at https://www.availity.com or by going to the provider website at https://providers.anthem.com/va > Login. Contracted and noncontracted providers unable to access Availity can call Provider Services for assistance with PA requirements:
- Anthem HealthKeepers Plus, Medallion Provider Services: 800‑901‑0020
- Anthem CCC Plus Provider Services: 855‑323‑4687
July 2021 Anthem Provider News - Virginia