Connecticut Precertification/Prior Authorization List
List of services requiring precertification/prior authorization for Connecticut Anthem Blue Cross and Blue Shield commercial HMO and PPO plans; identifies responsible parties and contact pathways for utilization management.
No material clinical or coverage changes in this revision.
Coverage Criteria Summary
If precertification/prior authorization is not obtained prior to the service, claim payment may be reduced or deemed ineligible for reimbursement. For HMO plans the participating provider or facility must contact the Utilization Management Department at 800-238-2227 to obtain precertification/prior authorization; for PPO plans providers or members should contact the Utilization Management Department at 800-238-2227 (the precertification number also appears on the member's ID card). In situations where precertification is the provider's responsibility and it is not secured, the plan may deny or reduce payment while the member must be held harmless for provider responsibilities under HMO products.
Provider Responsibilities & Prior Authorization
Obtain precertification/prior authorization from UM or Carelon MBM
Participating providers or the facility performing the service must obtain precertification/prior authorization by contacting the Utilization Management Department at 800-238-2227 or Carelon Medical Benefits Management (Contact Center 866-714-1107) or via Carelon MBM online portals (Availity or providerportal.com). The request must come from the care provider or facility rendering the service (not the referring physician, except where noted).
- HMO plans: provider or facility must contact Utilization Management at 800-238-2227 to obtain precertification/prior authorization; request must come from the provider/facility performing the service. [[CITED ABOVE]]