Guideline Updates Prior AuthorizationHealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsMay 24, 2023

Prior Authorization Requirement Changes Effective July 1, 2023

Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.

Effective July 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by HealthKeepers, Inc. for Anthem HealthKeepers Plus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

81170

ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (for example, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain

81324

PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis

81325

PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis

81326

PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant

To request PA, you may use one of the following methods:

  • Web: Once logged in to Availity Essentials* at http://availity.com.
  • Fax: 800-964-3627
  • Phone: 800-901-0020

Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://mediproviders.anthem.com/va/Pages/communications-updates.aspx on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Anthem HealthKeepers Plus Provider Services at 800-901-0020 for assistance with PA requirements.

UM AROW #4073
* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

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PUBLICATIONS: June 2023 Provider Newsletter