Changes in prior authorization for Anthem HealthKeepers Plus therapy requests

Medical necessity review

Effective for dates of service on or after August 1, 2024, HealthKeepers, Inc. will transition medical necessity review of therapy services for Anthem HealthKeepers Plus members to the rehabilitation solution offered by Carelon Medical Benefits Management, Inc.

The rehabilitation solution will apply to physical, occupational, and speech therapies. Beginning with dates of service on or after August 1, 2024, no prior authorization is required for Anthem HealthKeepers Plus members for the first eight treatment visits for each new therapy episode of care, per therapy discipline.

Episode of care

A new episode of care is defined as treatment for a new condition or treatment for a recurring condition for which a member has not been treated within the previous 90 days. Prior authorization will be required starting with the ninth treatment visit and all additional visits per episode of care. An episode of care will begin when an evaluation or re-evaluation code is billed for the member.

Initial evaluation date of service

If treatment CPT^® service codes are rendered at the initial evaluation date of service, the initial evaluation visit will count toward the treatment visits where no prior authorization is required.

Included members:

• Anthem HealthKeepers Plus members
• FAMIS members

Transition of outpatient therapy care

If your therapy facility has received a prior authorization of outpatient therapy services for an in-scope place of service setting for dates of service that extend past the effective date of August 1, 2024, the prior authorization will continue to be valid. Providers will not need to obtain a new prior authorization with Carelon Medical Benefits Management until after the initial eight treatment visits have been rendered.

If a provider requires an appeal on a prior authorization issued prior to the Carelon Medical Benefits Management go-live from the health plan, the appeal will follow the existing process through the health plan.

Therapy modifiers

Modifiers indicating the type of therapy are required to process your claim correctly and should be utilized on all evaluation and management and treatment code lines:

• GP: Physical therapy
• GO: Occupational therapy
• GN: Speech therapy

This will allow us to identify the correct episode of care so the claim will process. Claim lines without a modifier will reject for lack of information.

Training webinars

To help you prepare for this rehabilitation solution, we’re hosting a series of webinar sessions that are designed for providers and office staff who will be rendering therapy services and requesting prior authorization. Webinar sessions will cover the following topics:

• How the rehabilitation solution works
• For which members and services the rehabilitation solution will apply
• Additional resources
• Q&A

We strongly encourage you and your practice to participate, even if you are already familiar with the rehabilitation solution and the provider website through other health plans or specialty programs.

How to register for the webinars

Please register to attend at least one training opportunity. Your facility’s attendance at one of the following training opportunities is highly encouraged. Solution-specific training for Carelon Medical Benefits Management content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training.

How to submit a prior authorization request:

• Online: The Carelon Medical Benefits Management provider website is available 24/7, fully interactive, and processes requests in real-time using clinical criteria. To register, go to providerportal.com.
• By phone: Call Carelon Medical Benefits Management toll-free at 855-574-6480, Monday through Friday, between 8 a.m. and 5 p.m. ET.
  
  

Provider resources

The Rehabilitation Program website will help you learn more about the rehabilitation solution and access helpful information and tools.

For more information:

• Online: To learn more about Carelon Medical Benefits Management, visit carelon.com.
• By phone: Contact Anthem HealthKeepers Plus Provider Services at 800-901-0020.