This portlet is temporarily disabled.
null
null
null
null
null

Referrals and Preauthorization

PW_006531
 
Is a referral needed to see a specialist?
Anthem recently announced an "open access" policy for its Colorado HMO and Point-of-Service (POS) plan members - which means most members may visit any in-network physician specialist without a referral from their primary care physician (PCP) simply by scheduling an appointment for their visit. Child health Plan Plus (CHP+) members still must obtain a referral from their PCP to see a specialist. 
HMO members may select physician specialists from our extensive provider network of health care professionals. However, for the best possible coordination of overall care and for referral guidance, we encourage members to talk to their PCP. 
POS and PPO members may visit out-of-network physician specialists without a referral although such visits may result in higher out-of-pocket costs. To receive the highest level of benefits, we encourage members to choose a specialist who participates in our provider network
What a referral includes. A referral typically includes the office visit and any routine lab work or in-office x-rays that may be performed. When other services or procedures occur during an office visit (such as medication injections or minor skin surgery), preauthorization may be required. 
Coverage for services is governed by the benefits and exclusions listed in your certificate and Health Plan Description Form. You may contact Customer Service at the number on the back of your health plan ID card to determine if a visit to a physician specialist requires a referral or if procedures performed during the visit require preauthorization. 
What does "preauthorization" mean?
Preauthorization, sometimes referred to as "pre-certification," is the process used to confirm if a proposed service or procedure is medically necessary. Whenever possible, preauthorization should occur before treatment is received. 
The physician who schedules an admission or orders the procedure or service is responsible for obtaining preauthorization. Providers should contact the Provider Authorization number on the back of the health plan ID card to confirm if preauthorization is required. 
You may also contact Customer Service at the number on the back of your health plan ID card to determine if a proposed test, equipment, service, or procedure requires preauthorization. 
It is important to know if your provider has obtained preauthorization, particularly when visiting an out-of-network provider who may or may not be familiar with Anthem's policies and requirements. 
What services or procedures require preauthorization?
Please refer to your certificate and Health Plan Description Form for details about covered benefits, copayments, coinsurance, deductibles and exclusions. Many of the services you may receive require preauthorization, even if the physician office visit itself does not require a referral. 
The physician who schedules an admission or orders the procedure or service is responsible for obtaining preauthorization. In-network providers will know how to contact Anthem at the Provider Authorization number on the back of your health plan ID card for benefit coverage information and to obtain preauthorization for the care you may be scheduled to receive. 
Out-of-network providers may not always know Anthem's specific preauthorization requirements. We recommend that you confirm with your out-of-network provider(s) that preauthorization (or "pre-certification"), if required, has been obtained. Typically, services requiring preauthorization include: 
Overnight stays at a facility, such as a hospital or rehabilitation facility, or continued stays past the number of days authorized.
Emergency Admissions. HMO members must notify their health plan within one business day, if reasonably possible, after being admitted to a hospital.
Surgical procedures, radiology tests, and occupational, speech and physical therapy visits.
Behavioral health (mental health) care and alcohol/chemical dependency rehabilitation services. You or your physician must contact Anthem Behavioral Health toll free at 800-424-4012 to obtain preauthorization or otherwise coordinate these services.
 
Preauthorization Requirements
Locate your plan below to view a partial listing of preauthorization requirements. Preauthorization requirements are subject to change at any time and without notice. We therefore encourage you to contact Customer Service at the number on the back of your health plan ID card to determine if a particular test, equipment, service or procedure requires preauthorization before receiving services or treatment. 
 

BluePreferred PPO for Individuals 
BlueAdvantage HMO 
BlueAdvantage Point-of-Service (POS) 
Basic and Standard HMO 
BasicBlue HMO 
Child Health Plan Plus 
BluePreferred PPO for Groups 
BlueFreedom 
BasicBlue PPO 
Custom Plus for Groups/Indemnity 
Preferred Plus for Groups 
Prime PPO 
Basic and Standard PPO 
State of Colorado Centennial and Liberty/PPO and EPO 
BlueCard® Point-of-Service (POS) 
Colorado Major Medical for Individuals 
 
When do I need to obtain preauthorization?
When and in-network provider orders a service or procedure, that provider is responsible for obtaining preauthorization. 
When an out-of-network provider orders a service or procedure, you must confirm with that provider that preauthorization has been obtained and/or call Customer Service to determine if preauthorization is required. This is especially important because out-of-network providers may not be completely familiar with Anthem policies. 
Receiving treatment without obtaining preauthorization may result in higher out-of-pocket costs for you or the denial of benefits. When preauthorization is obtained, coverage is provided up to your health plan's maximum benefit allowance. Benefits are not provided when: 
preauthorization is not obtained; or
preauthorization is requested, but services are determined to be not medically necessary.
 
View a list of preauthorization requirements for specific services and procedures. You may also contact Customer Service at the number on the back of your health plan ID card to determine if a proposed test, equipment, service or procedure requires preauthorization. 
What if my health plan does not grant preauthorization for a service?
The preauthorization requirements chart lists services and procedures most often asked about. Preauthorization requirements are subject to change at any time and without notice. Contact Customer Service at the number on the back of your health plan ID card to determine if a proposed test, equipment, services or procedure requires preauthorization. 
If preauthorization for a particular service or treatment is denied, you may be held financially responsible for the expense of the test, equipment, service or procedure. Please refer to your certificate and Health Plan Description Form for details about benefits and exclusions. 
You or your representative may appeal the health plan's preauthorization decision by following the procedure outlined in Complaints and Appeals. If you or your provider sought approval from us and the request for benefits was denied, you or your provider may request that we reconsider our decision if you believe we did not have all of the necessary information at the time of the decision. 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use