Prior authorization requirement changes effective December 1, 2021

Summary of update

Effective December 1, 2021, prior authorization (PA) requirements will change for 0018U and 0245U. The medical codes listed below will require PA by Anthem Blue Cross and Blue Shield for BadgerCare 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.

 

Please note: Noncompliance with new requirements may result in denied claims.

 

What medical codes will now require PA?

PA requirements will be added to the following:

• 0018U — Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy
• 0245U — Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of four mRNA markers using next-generation sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage

 

How do I request a PA?

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

• Through the Availity Portal:* Once logged in to Availity at com, select Patient Registration > Authorizations & Referrals > Choose either Authorizations or Auth/Referral Inquiry, as appropriate.
• By fax: 800-964-3627
• By phone: 855-558-1443

 

Are all PA requirements listed in this update?

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at https://providers.anthem.com/wi. You must log in to see detailed PA requirements. Contracted and noncontracted providers who are unable to access Availity may call Provider Services at 855 558-1443 for assistance with PA requirements.

 

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Experience associate or call Provider Services at 855-558-1443.

 

AWI-NU-0317-21