Anthem Blue Cross and Blue Shield in Connecticut Precertification Guidelines
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1 Anthem Blue Cross and Blue Shield in Connecticut Precertification Guidelines The following guidelines apply to Anthem Blue Cross and Blue Shield ( Anthem ) products issued and delivered by Anthem in Connecticut. For information on precertification requirements for those members of National Accounts please see <Precertification Requirements for Groups Enrolled in National Accounts > To verify member eligibility, benefits and account information please call the telephone number listed on the back of the member s identification card. Prior authorization is the determination by Anthem that selected inpatient and outpatient medical services (including surgeries, major diagnostic procedures and referrals) are medically necessary. For the member to receive maximum benefits, Anthem must authorize the services for which prior authorization is required prior to being rendered. Prior authorization can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider. Prior authorization 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 authorized 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 the member and the physician or provider of service. 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. Responsibility for Prior Authorization: For HMO type health plans: Under our HMO plans and products: It is the participating physician s or provider s responsibility to contact Anthem s Utilization Management Department at (800) , or such other number indicated below for specific services, to obtain prior authorization. The request must come from the provider or facility rendering the service, not the referring physician, except where described below for specific services. If prior authorization is not obtained, the claim payment may be reduced or denied by the Plan and the member must be held harmless. For PPO type health plans: Under our PPO plans and products: Services provided by a network provider: The provider is responsible for prior authorization. 1
2 Services provided by a BlueCard or non-participating provider: The member is responsible for prior authorization. The member is financially responsible for services and/or settings that are not covered under the certificate based on an adverse determination of medical necessity or experimental or investigational services. Contact Anthem s Utilization Management Department to obtain precertification at: (800) , or such other number indicated below for specific services. The precertification number is listed on the back of the member s Anthem ID card. Inpatient Surgical/Inpatient Medical Admission Precertification is required for the following services: Elective admissions Emergency admissions - Anthem must be notified within 48 hours or two business days Gastric bypass surgery Human organ and bone marrow/stem cell transplants Inpatient hospice Inpatient rehabilitation admissions Inpatient skilled nursing facility admission OB (obstetrical) related medical stay, excludes childbirth 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 48 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. Precertification is required for the following services Ablative techniques for treating Barrett s esophagus ALCAT Blepharoplasty, blepharoptosis repair, and brow lift Breast surgery (female and male excluding breast biopsy) Cochlear implant and auditory brain stem implant Cranial/facial surgery Genetic testing Hyperbaric oxygen therapy (systemic/topical) Implantable infusion pumps Intraocular implant/shunt Locally ablative techniques for treating primary and metastatic liver malignancies 2
3 Lung volume reduction surgery Maze procedure Nasal/sinus surgery Out of network referrals/services Physical therapy and occupational therapy see below Polysomnography and home portable monitors (review to be done by AIM Specialty Health SM (AIM)) Potential cosmetic/reconstructive procedures of the skin, head/neck, upper extremity, or lower extremity Sclerotherapy Selected diagnostic testing: e.g. sleep disorders Selected injectable therapy- e.g. Synagis, growth hormone Selected outpatient surgery: e.g. TMJ, varicose veins, total ankle replacement, Gender reassignment, transcatheter uterine artery embolization Some outpatient diagnostic imaging see below Specialized durable medical equipment customized equipment Stem cell/bone marrow transplant (with or without myeloablative therapy) and donor leukocyte infusion Testicular/penile prosthesis Tonsillectomies in children Treatment of hyperhidrosis Uvulopalatopharyngoplasty (UPP) Venticulectomy/cardiomyoplasty Wearable cardioverter-defibrillators Precertification is recommended for the following services Air and water ambulance Ambulatory EEG Cooling Devices and Combined Cooling/Heating Devices Electrical bone growth stimulator Infertility treatment Myocardial sympathetic innervations imaging with or without SPECT Neuromuscular stimulator Oral infant formula Outpatient Hysterectomy Private duty nursing Select specialty pharmacy drugs - e.g., ESA (erythropoesis stimulating agents) Epogen, Procrit, Aranesp, IVIG, Remicade requests for precertification can be obtained through Anthem Utilization Management or AIM. See instructions below on using AIM s ProviderPortal SM Spinal surgery Therapeutic Apheresis 3
4 Prior authorization is required through AIM for the following services/procedures/treatments Prior authorization is required through AIM for the following non-emergent outpatient services for members of most of our commercial plans and products: CT Echo cardiology [stress echocardiography (SE), transesophageal echocardiography (TEE), and resting transthoracic echocardiography (TTE)] Polysomnography and home sleep study MLST (multi-level Sleep Study) MRA MRI Nuclear cardiology PET Radiation therapy (IMRT, proton beam, brachytherapy, SRS, SBRT) Providers may contact AIM for prior authorization of the services listed above through the following options: Online prior authorization via AIM s ProviderPortal SM at The ProviderPortal is fully interactive, processing prior authorization in real-time using proprietary clinical criteria twenty-four hours/day, seven days/week. Via telephone to AIM toll-free at , Monday Friday, 8:00 am - 5:00 pm. Providers can either request a prior authorization or verify that an order number has been issued. Services listed above are effective and current as of March For benefits to be paid, the member must be eligible on the date of service and the service must be a Physical Therapy and Occupational Therapy through Orthonet Precertification is required through Orthonet for outpatient physical and occupational therapy following the initial evaluation, for members of most of our commercial plans and products as of January 1, The program consists of a utilization management program and a consultation management program. Under the utilization management program, all outpatient physical and occupational therapy services following the initial evaluation will require prior authorization through OrthoNet. The consultation management program will focus on providing our network providers with clinical consulting services to help support decisions regarding the clinical effectiveness of physical and occupational services. For both programs, the rendering physical or occupational therapy provider/facility should contact OrthoNet since they will have the clinical details and information needed for the review. Please note that the initial evaluation does not require prior authorization. Please contact Orthonet to obtain precertification for these services at 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. 4
5 Mental Health/Substance Abuse Services Anthem's mental health and substance abuse benefits in Connecticut are administered by professionals who are specially trained to handle referrals and coordinate care for mental health and substance abuse. Call (800) for: Inpatient behavioral health and substance abuse admissions Partial hospital program (PHP) Intensive outpatient programs (IOP) Outpatient electroconvulsive therapy (ECT) Pre-certification for psychological testing and outpatient services varies by products and plan, please contact the appropriate state s customer service number for requirement or when verifying eligibility. Professionals are available 24 hours a day, seven days a week. UM Decisions- Appropriateness of Care and Services As part of our goal to improve the health of the members we serve, we are committed to promoting appropriate utilization of medical services. Please note the following: Individuals who make utilization management decisions do not receive compensation or incentives to deny care. This also applies to individuals who supervise them, including management, medical directors, utilization management managers and licensed staff. Utilization management decisions are based only on appropriateness of care and services and existence of coverage. The plan does not specifically reward for denial of services, or offer incentives to encourage denial of services. UM Criteria is Available to Physicians/Providers Physicians and health care providers may request that we provide the specific criteria utilized to render a medical necessity determination. If a treating physician or provider would like to request a copy of specific UM criteria, they may call the Utilization Management Department at: (800) Physician Reviewers are Available to Discuss Utilization Management Decisions Our physician reviewers are involved in utilization management determinations that result in a denial of benefits and are available to discuss the determinations by calling (800) For details on Pharmacy Precertification Requirements please visit our pharmacy website. (link available on the Provider Home page) 5
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Gold 80 PPO Network Name: Exclusive Coverage Period: Beginning on or after 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type:
Medical Plan - Healthfund
18 Medical Plan - Healthfund Oklahoma City Community College Effective Date: 07-01-2010 Aetna HealthFund Open Choice (PPO) - Oklahoma PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY -
PPO product with drug plan being offered for January 1, 2013
PPO product with drug plan being offered for January 1, 2013 Austin area: 8 counties Dallas/Fort Worth area: 4 counties Houston area: 3 counties Austin Area Counties (8) Bastrop Burnet Caldwell Fayette
Individual. Employee + 1 Family
FUND FEATURES HealthFund Amount Individual Employee + 1 Family $750 $1,125 $1,500 Amount contributed to the Fund by the employer is reflected above. Fund Amount reflected is on a per calendar year basis.
American Maritime Officers Medical Plan Employer Identification Number: 13-5600786 Plan Number: 501 Group Number: 0081717
AMENDMENT #4 American Maritime Officers Medical Plan Employer Identification Number: 13-5600786 Plan Number: 501 Group Number: 0081717 This Amendment is duly adopted and effective as of October 1, 2014.
HUSKY Health Benefits and Prior Authorization Requirements Grid* Hospital Outpatient Effective: January 1, 2012
Cardiac Rehab 100% covered 100% covered 100% covered Dialysis 100% covered 100% covered 100% covered Emergency Care Covered no co- pays for Emergency Room visits Covered no co- pays for Emergency Room
Important Questions Answers Why this Matters: In-network: $2,000 Single / $4,000 Family Out-of-network: $3,000 Single / $6,000 Family
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.independenthealth.com or by calling 1-800-501-3439. Important
PREFERRED CARE. All covered expenses, including prescription drugs, accumulate toward both the preferred and non-preferred Payment Limit.
PLAN FEATURES Deductible (per plan year) $300 Individual $300 Individual None Family None Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred and non-preferred