Prior authorization requirement changes updated effective November 1, 2022

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 November 1, 2022, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by HealthKeepers, Inc. 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:

 

• 0214U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O
• 0215U: Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood O
• 81415: Exome (such as unexplained constitutional or heritable disorder or syndrome); sequence analysis
• 81416: Exome (such as unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (such as parents, siblings) (List separately in addition to code for primary procedure)
• 81417: Exome (such as unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (such as updated knowledge or unrelated condition/syndrome)
• L6026: Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device
• L6715: Terminal device, multiple articulating digit, includes motor(s), initial issue, or replacement

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

 

• Availity:* Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry, as appropriate.
• Fax: 800-964-3627
• Phone: 800-901-0020

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/va. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 800-901-0020 for assistance with PA requirements.

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

 

* Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

 

AVA-NU-0571-22