In response to your concerns about unique billing requirements and retrospective medical review for specialty drugs, Anthem Blue Cross offers pre-service medical review in an effort to speed payment to providers and to help monitor the appropriateness of the dose and frequency of specialty drugs for our members.
Effective May 5, 2007, we implemented Pre-Service Medical Review of Specialty Drugs that are provided under a member’s medical benefits.
The pre-service medical review program has three goals:
| Review dose and frequency of specialty drugs |
| Pre-identify members for case management |
| Eliminate provider abrasion by helping decrease claims processing time |
This important change in our Utilization Management (UM) review process could directly affect how you get paid for rendering services to our members.
While you are not required to use this process, your claims will continue to be subjected to the current retrospective medical review process if you do not receive pre-service review approval.
Click the following links for:
Note: Pre-service medical review is applicable for Anthem Blue Cross’ PPO members. Additionally, select members may not require pre-service medical review depending on their elected benefits. Please see the FAQ link above for more specific information. For additional information, please call our UM department at 800-274-7767.
How do I obtain a pre-authorization?
| Download the pre-service review form for the medication being requested. |
| Complete the form in its entirety and attach all necessary supporting information, e.g. labs, notes, etc. |
Fax the completed form and all supporting information to 866-408-7195.