Anthem Blue Cross and Blue Shield | CommercialOctober 1, 2023
Prior authorization requirement changes effective January 1, 2024
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 emergency room (ER)/Urgent Care and authorized services.
To request precertification, 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 use disorder 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 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0260U | 1/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0264U | 1/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0265U | 1/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0266U | 1/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0267U | 1/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0332U | 1/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0335U | 1/1/2024 |
GENE.00052 | Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling | 0336U | 1/1/2024 |
GENE.00057 | Gene Expression Profiling for Idiopathic Pulmonary Fibrosis | 81554 | 1/1/2024 |
LAB.00011 | Selected Protein Biomarker Algorithmic Assays | 0080U | 1/1/2024 |
LAB.00011 | Selected Protein Biomarker Algorithmic Assays | 0247U | 1/1/2024 |
LAB.00011 | Selected Protein Biomarker Algorithmic Assays | 0249U | 1/1/2024 |
LAB.00011 | Selected Protein Biomarker Algorithmic Assays | 0360U | 1/1/2024 |
LAB.00015 | Detection of Circulating Tumor Cells | 0337U | 1/1/2024 |
LAB.00015 | Detection of Circulating Tumor Cells | 0338U | 1/1/2024 |
LAB.00019 | Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease | 0002M | 1/1/2024 |
LAB.00019 | Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease | 0003M | 1/1/2024 |
LAB.00019 | Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease | 0344U | 1/1/2024 |
LAB.00019 | Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease | 81596 | 1/1/2024 |
LAB.00024 | Immune Cell Function Assay | 86352 | 1/1/2024 |
LAB.00027 | Selected Blood, Serum and Cellular Allergy and Toxicity Tests | 86343 | 1/1/2024 |
LAB.00033 | Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer | 0228U | 1/1/2024 |
LAB.00033 | Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer | 0359U | 1/1/2024 |
LAB.00037 | Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) | 0164U | 1/1/2024 |
LAB.00037 | Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS) | 0176U | 1/1/2024 |
LAB.00041 | Machine Learning Derived Probability Score for Rapid Kidney Function Decline | 0105U | 1/1/2024 |
LAB.00046 | Testing for Biochemical Markers for Alzheimer's Disease | 0346U | 1/1/2024 |
LAB.00046 | Testing for Biochemical Markers for Alzheimer's Disease | 0358U | 1/1/2024 |
LAB.00046 | Testing for Biochemical Markers for Alzheimer's Disease | 0361U | 1/1/2024 |
LAB.00048 | Pain Management Biomarker Analysis | 0117U | 1/1/2024 |
MED.00004 | Noninvasive Imaging Technologies for the Evaluation of Skin Lesions | 0658T | 1/1/2024 |
MED.00004 | Noninvasive Imaging Technologies for the Evaluation of Skin Lesions | 96904 | 1/1/2024 |
SURG.00092 | Implanted Devices for Spinal Stenosis | 0202T | 1/1/2024 |
SURG.00092 | Implanted Devices for Spinal Stenosis | C1821 | 1/1/2024 |
* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc.
VABCBS-CM-037998-23
PUBLICATIONS: October 2023 Provider Newsletter
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