Precertification Guidelines
PW_A083983
Precertification Guidelines for Medicare Advantage
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 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 Anthem Senior Advantage, Anthem Medicare Preferred or Blue Medicare Access coverage. If you visit an out-of-network provider, precertification is your responsibility. Regardless of whether you visit a doctor/facility in the network, or out-of-network, it is always a good idea to ask your provider if the services have been precertified.
The Precertification number is listed on the back of your Anthem ID card.
Inpatient Surgical/Inpatient Medical Admission
| Elective admissions |
| Emergency admissions (Anthem must be notified within 24 hours) |
| OB (obstetrical) related medical stay, excludes childbirth |
| 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) |
| 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 |
| Non-emergent air and water transportation |
| 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 |
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. 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. 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.
Notification is required for the following services for all Medicare Advantage plans (ASA, AMP, or BMA):
| | When a member is initiated on renal dialysis. Please provide us with a copy of the CMS 2728-U3 Form |
| | When a member elects the Hospice Benefit. Please include the terminal diagnosis and date of admission |
HMO Plan members (ASA) only: Authorization is required for any services/procedures outside the network (including vision hardware)
For HMO Plan members, written documentation of the PCP referral to a plan specialist is still required in the patient’s chart, however, no call or fax to Anthem is necessary when referring to in-network providers. Fax authorization request to (513)336-3881, 24 hours a day, or call Anthem at (800)304-9919, during normal business hours.
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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