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Precertification and Predetermination For Services Other Than Radiology

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Precertification Requirements and Guidelines

Medical/surgical services and specialty pharmacy drugs that require precertification are listed here for Wisconsin local products.

Precertification Data Submission Tools

The following tools are available for guiding submissions of clinical information for preauthorization and/or predetermination requests:

Clinical Data Submission Tools – Medical/Surgical and Specialty Pharmacy

These tools are used to submit clinical information for select precertification or predetermination requests. If used, chart records and letters of medical necessity are generally not required.

Patient Demographics Submission Template

This template is used by admitting offices or business offices when notifying of a patient’s admission when clinical information is not available.

Clinical Review Submission Template

This template is used by hospital utilization management departments when submitting clinical information.

Combined Patient Demographics and Clinical Review Submission Template

This tool is used by offices or hospitals when requesting and/or reporting hospital admissions when both the demographic and clinical information are available. It may also be used to request outpatient services when both demographic and clinical information are available.

E-Review

E-Review is an innovative web-based tool that allows providers, clinics and facilities to communicate their request for services via a secured, HIPAA compliant e-mail to/from the associates of the Medical Management departments of Anthem. Using the E-Review process and the submission tools above is an efficient and economical method for precertification and predetermination requests. Contact Medical Management for additional information and to be set up for E-Review.

E-Review Quick Tips

Links to tips on using the e-review process in WI.

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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