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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements
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Lunemos Consumer Directed Health Plans

PW_AD084507
Precertification Guidelines for Lumenos Health Savings Account, Lumenos Health Reimbursement Account, Lumenos Health Incentive Account, Lumenos Individual Health Savings Account, Lumenos Individual Health Incentive Account, Lumenos Individual Health Incentive Account Plus 
Inpatient Admission:
Elective Admissions
Emergency Admissions (Anthem requires Plan notification within 24 hours)
OB Related Medical Stay(OB complications, Excludes childbirth admissions)
Newborn Stays beyond Mother
Inpatient Skilled Nursing Facility (SNF)
Long Term Acute Care Facility (LTAC)
Rehabilitation facility admissions
Inpatient Hospice respite care
Bariatric surgery
 
Outpatient Services
Bariatric surgery
Radiology services:

Nuclear Cardiac

CT Scan(includes CTA)

MRI,

MRA,

MRS

PET

 
Human Organ and Bone Marrow/Stem Cell Transplants (Predetermination of Benefits is required)  
Inpatient admits for ALL solid organ and bone marrow/stem cell transplants (Included Kidney only transplants) 
All Outpatient services for the following: 

Stem Cell/Bone Marrow transplant (with or without myeloablative therapy)

Donor Leukocyte Infusion

 
Out of Network Referrals: 
Out of Network Referrals (may be pre-authorized, based on network availability and or medical necessity.) 
 
Mental health/Substance Abuse (MHSA):  
All facility based care-

Inpatient admissions,

Intensive outpatient program, (IOP)

Partial Hospitalization program, (PHP)

Residential Care,

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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