Anthem National Accounts Prior Auth Policy Update

Inpatient admissions: Acute inpatient; acute rehabilitation; long term acute care hospital (LTACH); OB delivery stays beyond the federal minimum (including newborn stays beyond mother’s stay); skilled nursing facility. For emergency care admissions, precertification is not required but plan notification should be provided as soon as possible.

Diagnostic testing: Breast cancer (BRCA) genetic testing; gene expression profiling for breast cancer management; chromosomal microarray analysis (CMA) for developmental delay/autism/intellectual disability/congenital anomalies; gene mutation testing for cancer susceptibility and management; genetic testing for Lynch syndrome, FAP/attenuated FAP, MYH-associated polyposis; genetic testing for inherited diseases; preimplantation genetic diagnosis; testing for biochemical markers for Alzheimer’s disease; prostate saturation biopsy; whole genome sequencing, whole exome sequencing, gene panels, molecular profiling; wireless capsule for evaluation of suspected gastric and intestinal motility disorders.

Durable medical equipment/prosthetics: Functional electrical stimulation (FES)/threshold electrical stimulation (TES); high-frequency chest compression devices; intrapulmonary percussive ventilation devices; implantable infusion pumps; microprocessor controlled knee-ankle-foot orthosis; myoelectric upper extremity prosthetics; microprocessor controlled lower limb prosthesis; neuromuscular electrical training for obstructive sleep apnea/snoring; robotic arm assistive devices; noninvasive electrical bone growth stimulation of the appendicular skeleton; standing frames; ultrasonic diathermy devices; ultrasound bone growth stimulation; powered wheeled mobility devices.

Transplants, cellular/gene therapies, and related therapies: All transplant procedures and transplant-related services (outpatient and inpatient) including solid organ and bone marrow/stem cell transplants (including kidney-only), donor leukocyte infusion, CAR T-cell therapies (examples listed in policy), and stem cell/bone marrow transplant with or without myeloablative therapy. Gene replacement/therapy requires confirmation if group has excluded the benefit; if covered, pre-certification is required (examples listed: Zolgensma, Luxturna, therapies for hemophilia, CALD, beta thalassemia, Duchenne, metachromatic leukodystrophy, sickle cell disease).

Mental health and substance abuse (MHSA): Acute inpatient admissions; transcranial magnetic stimulation (TMS); residential care; behavioral health in-home programs; applied behavioral analysis (ABA) (precertification recommended and applies unless the group opts out; retrospective review allowed); intensive outpatient therapy (IOP); partial hospitalization (PHP). Check benefits for exclusions or specific precertification requirements.

Other outpatient and surgical services: Includes but is not limited to: Aduhelm (aducanumab); ambulance services (air and water, excludes 911-initiated emergency transport); ablative techniques for Barrett’s esophagus; allogeneic/xenographic/synthetic/bioengineered/composite wound healing and soft tissue grafting products; insertion/injection of prosthetic material (collagen implants); axial lumbar interbody fusion; balloon sinus ostial dilation; bariatric surgery and other treatments for clinically severe obesity (if covered, pre-certification is required); blepharoplasty/blepharoptosis repair/brow lift; breast procedures including reconstructive surgery and implants; bone-anchored and bone conduction hearing aids; bronchial thermoplasty; cardiac resynchronization therapy (CRT) with/without ICD; cardiac contractility modulation therapy; carotid/vertebral/intracranial artery stent placement; cardioverter defibrillators; cochlear and auditory brainstem implants; cosmetic and reconstructive head/neck procedures; minimally invasive posterior nasal nerve treatment for rhinitis; oral/pharyngeal/maxillofacial surgery for OSA/snoring; nasal surgery for OSA/snoring; outpatient cardiac hemodynamic monitoring using wireless sensor; panniculectomy/abdominoplasty; partial left ventriculectomy; PFO and left atrial appendage closure devices; penile prosthesis implantation; percutaneous and endoscopic spinal surgery; percutaneous neurolysis for chronic neck/back pain; perirectal spacers for prostate radiotherapy; vertebroplasty/kyphoplasty/sacroplasty; presbyopia/astigmatism-correcting intraocular lenses; private duty nursing in the home; reduction mammaplasty; sacral nerve stimulation/PTNS; sacral nerve stimulation for neurogenic bladder; sacroiliac joint fusion (open); Sipuleucel-T; surgical/ablative treatments for chronic headaches; therapeutic apheresis; total ankle replacement; transcatheter ablation for pulmonary vein foci; transcatheter heart valve procedures; transendoscopic therapy for GERD/dysphagia/gastroparesis; transmyocardial/perventricular device closure of VSD; treatment of osteochondral defects; treatment of temporomandibular disorders.

Radiation therapy and radiology services: Absolute quantitation of myocardial blood flow measurement; catheter-based embolization procedures for malignant lesions outside the liver; cryosurgical or radiofrequency ablation for solid tumors outside the liver; MRI-guided high intensity focused ultrasound ablation for non-oncologic indications; intensity modulated radiation therapy (IMRT); proton beam therapy; radioimmunotherapy and somatostatin receptor targeted radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin); stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT); wireless capsule endoscopy for GI imaging and patency capsule; Xofigo (radium Ra 223 dichloride).

Out-of-network referrals: Out-of-network services may be authorized at in-network benefit level based on network availability and/or medical necessity.

Provider Requirements and Authorization Process

Prior Authorization

Inpatient admission precertification

Precertification is required for inpatient admissions including acute inpatient, acute rehabilitation, long term acute care hospital (LTACH), obstetric deliveries beyond federally mandated minimum stay (including newborn stays beyond the mother's stay), skilled nursing facility stays, and other inpatient admissions. For emergency admissions, precertification is not required; however, the plan must be notified as soon as possible after the admission.

Prior Authorization

Outpatient/surgical and diagnostic precertification

Precertification is required for a broad range of outpatient, surgical, diagnostic, radiation therapy, and durable medical equipment/prosthetics services. Examples include advanced diagnostic testing (genetic testing such as BRCA, chromosomal microarray analysis, whole exome/genome sequencing, gene panels, and other molecular profiling; gene mutation testing for cancer susceptibility; preimplantation genetic diagnosis; testing for Alzheimer biomarkers; prostate saturation biopsy; wireless capsule endoscopy for GI evaluation), many elective and specialty outpatient surgical procedures, and selective radiology/radiation therapies.

Diagnostic testing: BRCA testing, CMA, whole exome/genome sequencing and gene panels, gene mutation testing for cancer susceptibility, Lynch syndrome/FAP/MYH testing, preimplantation genetic diagnosis, Alzheimer biochemical marker testing, prostate saturation biopsy, wireless capsule for GI motility evaluation
Durable Medical Equipment/Prosthetics: functional electrical stimulation, implantable infusion pumps, myoelectric prosthetics, microprocessor-controlled orthoses/prostheses, powered wheeled mobility devices, standing frames, ultrasonic/ultrasound bone growth stimulation, and other listed devices
Other outpatient/surgical services: numerous procedures including bariatric surgery (when covered), cochlear implants, cardiac devices and procedures, spinal procedures, cosmetic/reconstructive procedures, ENT and sinus procedures, ambulatory services (see full vendor list for specifics)
Radiation/radiology services: IMRT, proton beam therapy, SRS/SBRT, radioimmunotherapy, catheter-based embolization for malignant lesions, MRI-guided HIFU, and related advanced radiation therapies

Prior Authorization

Transplants, cellular/gene therapy, and gender-affirming surgery

Transplants, cellular and gene therapies, and related specialized treatments require precertification. This includes inpatient admissions for all solid organ and bone marrow/stem cell transplants (including kidney-only), donor leukocyte infusion, CAR T‑cell therapies (examples listed), stem cell/bone marrow transplants (with or without myeloablative therapy), and specified gene replacement therapies. For gene therapies and gender-affirming surgery where coverage is excluded by the group, clear confirmation of exclusion is required; if covered, pre-certification is required.

Transplants: all solid organ and bone marrow/stem cell transplants (inpatient admits), donor leukocyte infusion, stem cell/bone marrow transplant procedures
Cellular/CAR-T therapies: examples include axicabtagene ciloleucel (Yescarta), tisagenlecleucel (Kymriah), lisocabtagene maraleucel (Breyanzi), idecabtagene vicleucel (Abecma), brexucabtagene autoleucel (Tecartus), carvykti (ciltacabtagene autoleucel), amtagvi (lifileucel)
Gene therapies: examples include onasemnogene abeparvovec‑xioi (Zolgensma), voretigene neparvovec‑rzyl (Luxturna), therapies for hemophilia, CALD, beta thalassemia (ZYNTEGLO), Duchenne muscular dystrophy, metachromatic leukodystrophy, and sickle cell disease — precertification required if the group covers these therapies
Gender-affirming surgery: if the employer group excludes the benefit, clear confirmation of exclusion is required; if covered, precertification is required

Documentation Required

Eligibility verification and vendor-managed precertification

Verify member eligibility and benefits prior to providing services. Service preapproval and coverage determination are based on the member's benefit plan and eligibility at the time the service is reviewed. Providers are responsible for verifying eligibility and covered benefits using the Anthem website or the phone number on the member's ID card. Note that benefit plans vary and may be subject to employer-specific customizations.

Verify eligibility/benefits via Anthem website or member ID card phone number
Service preapproval is based on member eligibility and benefits at time of review/approval
Providers are responsible for verification; NOC/unlisted codes may be reviewed at claim submission

Note

Eligibility verification and vendor-managed precertification

Some precertification programs and specialty benefits management are administered by vendor partners. Carelon Medical Benefits Management, Inc. manages precertification for certain services on behalf of Anthem National Accounts for eligible members. Determine whether a member is Vendor Program eligible by calling the phone number on the back of the member's ID card or visiting the Carelon site. When services/codes are noted as managed by Carelon, the precertification requirement applies only to Vendor Program eligible members.

Carelon-managed programs include: cardiovascular services, diagnostic imaging management, imaging level of care, genetic testing, musculoskeletal (MSK) program, outpatient sleep testing and therapy, and oncology drugs
For Vendor Program eligible members, precertification must be obtained through the vendor per instructions on the member ID card or vendor site
For services not requiring precertification for coverage, pre-determination is recommended when post-service claim edits or potential member cost exposure exist

Prior Authorization

Out-of-network referral authorization

Out-of-network services may be authorized for payment at the in-network benefit level in certain circumstances based on network availability and/or medical necessity. Providers should contact the plan to determine if an out-of-network referral authorization is appropriate.

Out-of-network referral authorization may be granted when network availability is limited or when medically necessary

Key Terms and Vendor Definitions

Carelon Medical Benefits Management

DefinitionCarelon Medical Benefits Management, Inc. is a separate company providing specialty benefits management on behalf of Anthem National Accounts for certain members.

Programs managedCarelon manages programs including cardiovascular services, diagnostic imaging management, imaging level of care, genetic testing, musculoskeletal (MSK) program, outpatient sleep testing and therapy services, and oncology drugs.

How to determine vendor involvementDetermine if preapproval is needed by calling the phone number on the back of the member's ID card or by contacting the Carelon Medical plan as indicated.

Vendor applicability notePrecertification requirement for codes noted as managed by Carelon applies only to Vendor Program–eligible members.

Precertification

DefinitionPrecertification (preauthorization) is a prior approval process required for specified services when covered under the member's benefit plan.

Emergency inpatient admissionsFor emergency inpatient admissions, precertification is not required; however, plan notification should be provided as soon as possible.

Scope for inpatient admissionsInpatient admissions requiring precertification include acute inpatient, acute rehabilitation, LTACH, OB delivery stays beyond federal minimum (including newborn beyond mother's stay), and skilled nursing facility stays.

Review basisService preapproval is determined based on the member's benefit plan/eligibility at the time the service is reviewed/approved.

OpenPayer

Anthem National Accounts standard prior authorization (precertification) requirements

Services Requiring Precertification

Claim Coding and Benefit Verification

Provider Requirements and Authorization Process

Key Terms and Vendor Definitions