Guideline Updates Prior AuthorizationAnthem Blue Cross and Blue Shield | CommercialMarch 12, 2024

Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. Precertification List Change Notification for September 2023

This article was previously posted with archived criteria CG-SURG-27 which has been removed. Previous article here.

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 prior authorization process.

HMO plans: Services that require precertification will be denied if rendered without the appropriate prior authorization 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.

To request precertification with the Virginia Plan

Access Availity Essentials (Availity.com).

For maternity, medical, surgical precertification, call the number listed on the back of the member’s ID card.

For mental health and substance abuse precertification, call 800-755-0851. Professionals are available 24 hours a day, seven days a week.

Add to precertification

Criteria

Criteria description

Code

Effective date

CG-DME-45

Ultrasound Bone Growth Stimulation

E0760

12/01/2023

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

VABCBS-CM-050242-24-SRS49080

PUBLICATIONS: April 2024 Provider Newsletter