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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements
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Precertification Guidelines

PW_A083976

Precertification Guidelines for Blue Access

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 (LTAC)
Skilled Nursing Facility admissions
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
Home health services:

Private Duty Nurse

UPPP surgery (Uvulopalatopharyngoplasty; removal of excessive soft tissue in the back of the throat to relieve obstruction.)
Plastic/Reconstructive surgeries (only specific procedure listed)

Blepharoplasty (eyelid surgery)

Rhinoplasty (nose surgery)

Hairplasty (Stretching scalp tissue to pull hair forward)

Panniculectomy and Lipectomy/Diatasis Recti Repair (surgical removal of fat deposits; excision of excessive skin and subcutaneous (under the skin)tissue)

Insertion/Injection of Prosthetic Material Collagen Implants

Chin Implant/Mentoplasty/Osteoplasty Mandible (reconstruction of jaw or face)

Certain DME/Prosthetics:

Wheelchairs, special size, motorized or powered, and accessories

Hospital Beds, Rocking Beds, and Air Beds

Electronic or externally powered prosthetics

Custom made Orthotics and braces

 
Radiology Services
PET
Nuclear Cardiac
CT Scan (includes CTA)
MRI
MRA
MRS
 
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 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.  
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
 
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.  
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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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