CurrentAnthemPolicy N/A
Anthem California Precertification / Reviewed-by Anthem Code List (partial)
Lists CPT/HCPCS/U/other codes that Anthem (and delegated vendors Carelon/CarelonRx) review or prior authorize for California commercial members; includes submission instructions (photos, mental health letters, CT reports), transplant and behavioral health contact points, and notes California SB 535 removing prior authorization for biomarker testing in advanced/metastatic (stage 3/4) cancer.
Policy Summary
PayerAnthem
PolicyAnthem California Precertification / Reviewed-by Anthem Code List (partial)
Policy CodePolicy N/A
Change TypeOperational code list (no material change)
Effective DateN/A
Next Review DateN/A
Key ActionVerify member eligibility and benefits and submit required documentation (photos, mental health letters, CT reports) to the responsible reviewer (Anthem or Carelon/CarelonRx) per the code comments.
POLICY UPDATE CHANGES
No material clinical/coverage changes in this brief — the document is a code list and operational guidance; no policy changes were reported.
CarelonResponsible party for most codes
Transgender-specificCodes with transgender surgery documentation
SB 535SB 535 biomarker PA removal
150+Approx. codes in extract
Transplant / BehavioralSpecial contacts called out
Policy Overview & Scope
Precertification / Review Rules & Routing
General Precertification/Review Rules and Applicability
General precertification/review rules and applicability. Preserve AND/OR logic for member/program applicability and SB 535 exception.
all of the following apply to precertification and review routing:
any of the following member/program applicability rules:
- Local fully-insured Anthem members and select ASO (self‑insured) members whose services are medically managed as part of a purchased program are subject to the precertification and clinical review rules described herein.
- Does NOT apply to HMO, BlueCard, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program (FEP).
Policy Summary
PayerAnthem
PolicyAnthem California Precertification / Reviewed-by Anthem Code List (partial)
Policy CodePolicy N/A
Change TypeOperational code list (no material change)
Effective DateN/A
Next Review DateN/A
Key ActionVerify member eligibility and benefits and submit required documentation (photos, mental health letters, CT reports) to the responsible reviewer (Anthem or Carelon/CarelonRx) per the code comments.
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