Precertification Guidelines
PW_A083965
Precertification Guidelines for BlueAccessSM, BluePreferred®, Blue Priority, BluePreferred® Primary, and BluePreferred® Primary Plus
Precertification is the determination that selected inpatient and outpatient medical services, including surgeries, major diagnostic procedures and referrals meet criteria for medical necessity under the member's benefits contract. For the member to receive maximum benefits, Anthem must authorize these covered services prior to being rendered. Precertification helps avoid unnecessary charges or penalties by ensuring that the member's care is administered at a network facility and by a network provider.
 | Precertification includes a review of both the service and the setting |
| Care will be covered according to the member’s benefits for the number of days precertified unless our concurrent review determines that additional days qualify for coverage. |
| Certain services may require the member to use a provider designated by Anthem’s Utilization Management staff |
| A copy of the approval will be provided to you, the physician and the hospital or facility |
| For benefits to be paid, the member must be eligible for benefits and the service must be eligible for benefits and the service must be a covered benefit under the contract at the time the services are rendered. |
Precertification Responsibility
Network physicians are required to obtain precertification for patients with Blue AccessTM, Blue Preferred® Primary or Blue Preferred® Primary Plus coverage. If you visit an out-of-network physician, precertification is your responsibility. Regardless of whether you visit a doctor in the network, or out-of-network, it is always a good idea to ask your physician if the services have been precertified.
Patients with Blue Traditional coverage are responsible for obtaining precertification.
The Precertification number is listed on the back of your Anthem ID card.
Inpatient Surgical/Inpatient Medical Admission
| Elective Admissions |
| Emergency Admissions (Anthem requires Plan notification within 24 hours) |
| OB Related Medical Stay (OB complications, Excludes childbirth) |
| Newborn Stays beyond Mother |
| Long Term Acute Care (LTAC) |
| Inpatient Skilled Nursing Facility |
| Rehabilitation facility admissions |
Services listed above are effective and current as of January 1, 2007. For benefits to be paid, the member must be eligible on the date of service and the service must be a covered benefit under the policy. This list is subject to change.
Outpatient Services:
| UPPP surgery (uvulopalatopharyngoplasty, uvulopharyngoplasty) |
| Plastic/Reconstructive surgeries: (Only specific procedures listed) |
 | | Blepharoplasty |
| | Rhinoplasty |
| | Hairplasty |
| | Panniculectomy and Lipectomy/Diatasis Recti Repair |
| | Insertion/Injection of Prosthetic Material Collagen Implants |
| | Chin Implant/Mentoplasty/Osteoplasty Mandible |
| DME/Prosthetics: recommendation is to verify benefits for all DME, and medical necessity on the list below |
| | Wheelchairs, special size, motorized or powered, and accessories |
| | Hospital Beds, Rocking Beds, and Air Beds |
| | Electronic or externally powered prosthetics |
| | Custom made and/or Custom fitted prefabricated orthotics and braces |
| Private Duty Nurse services in the home setting |
Radiology Services
| Nuclear Cardiac |
| CT Scan (includes CTA) |
| MRI |
| MRA |
| MRS |
| PET |
Services listed above are effective and current as of January 1, 2007. For benefits to be paid, the member must be eligible on the date of service and the service must be a covered benefit under the policy. This list is subject to change. Mental Health/Substance Abuse Services
Specially trained professionals will handle referrals and coordinate care for mental health and substance abuse. Call (800) 788-4003 for:
| Referrals to mental health and substance abuse treatment providers |
| General information about mental health and substance abuse benefits and treatment |
| Emergency and urgent care information and assistance |
| Inpatient admissions require authorization |
Professionals are available 24 hours a day, seven days a week.
Services listed above are effective and current as of January 1, 2007. For benefits to be paid, the member must be eligible on the date of service and the service must be a covered benefit under the policy. This list is subject to change. Transplant Precertification
Depending on the member's coverage, transplant services may be covered at a reduced benefit, or may not be covered at all, if:
| you fail to obtain precertification. |
| you use a provider other than the one designated by Anthem. |
Additional penalties may apply.
Human Organ and Bone Marrow/Stem Cell Transplants
All Inpatient admits for the following:
| Heart transplant |
| Liver transplant |
| Lung or double lung transplant |
| Simultaneous Pancreas/Kidney |
| Pancreas transplant |
| Kidney transplant |
| Small bowel transplant |
| Multi-visceral transplant |
| Stem cell/Bone Marrow transplant (with or without myeloablative therapy) |
All Outpatient services for the following:
| Stem Cell/Bone Marrow transplant (with or without myeloablative therapy) |
| Donor Leukocyte Infusion |
Referrals:
Out of network Referrals (may be pre-authorized, based on network availability and/or medical necessity)
No Precertification for Emergencies
Precertification is not required for emergency admissions. However, to ensure that members receive the maximum coverage possible, Anthem must be notified about the admission within 24 hours or as soon as reasonably possible. Failure to notify Anthem may result in denial of claims for services that we determine are not medically necessary under the benefits contract.
Services listed above are effective and current as of January 1, 2007. For benefits to be paid, the member must be eligible on the date of service and the service must be a covered benefit under the policy. This list is subject to change.
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