Precertification Guidelines
PW_A083973
Precertification Guidelines for Blue Traditional®
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 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 |
| Skilled Nursing Facility admissions |
| Rehabilitation Facility admissions |
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 |
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:
| Inpatient admissions require authorizations |
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. | 