Anthem and CDHP products Precertification/Prior Authorization List
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Defines services and procedures that require preapproval (precertification/prior authorization) for Anthem and CDHP products and identifies responsible parties and vendor-managed programs; applies to providers submitting requests for covered members in the included Blue Cross Blue Shield plan jurisdictions.
No material clinical or coverage changes in this revision.
Preapproval / Prior Authorization Applicability
Preapproval applicability
Services requiring preapproval when ALL of the following apply
Check state-specific listings and vendor program applicability; for Carelon-managed services submit requests via the Carelon Provider Portal or call the phone number on the member's ID card (Carelon toll-free 866-714-1103).
This Precertification/Prior Authorization requirement does not apply to members covered under BlueCard, Medicare Advantage, Medicaid, Medicare Supplement, or the Federal Employee Program (FEP). Certain items or criteria in this document apply only to local fully insured Anthem members and select self‑insured (ASO) plans when the service is managed as part of a purchased program; if the vendor program has not been purchased for a member’s plan, preapproval is not required and clinical review will not be performed for that member. For questions about applicability, contact Provider Services using the number on the back of the member’s ID card.
No additional applicability exceptions are specified in the provided excerpt beyond those listed in the Preapproval responsibility section. State‑ or program‑specific applicability should be confirmed by reviewing the member’s benefits and any vendor program participation for the plan.
Coding and Code Notes
| No codes listed |
Provider Requirements and Prior Authorization Process
Prior Authorization Required
Prior authorization required for listed services. Providers must obtain preapproval/prior authorization for the services and admissions enumerated on the Precertification/Prior Authorization List (including elective and emergency inpatient admissions, specified facility-based care, transplant services, bariatric and certain surgical procedures, specialty pharmacy medications managed by CarelonRx, and other listed procedures). Preapproval may be required for both the service and the setting. For Carelon-managed services, submit requests via Carelon Medical Benefits Management's Provider Portal or call the phone number on the member's ID card.
- Elective and emergency inpatient admissions (Anthem requires plan notification within 24 hours for emergency admissions).
- All inpatient admits for listed transplant types (hand, heart, kidney, liver, lung, multi-visceral, pancreas, simultaneous pancreas/kidney, small bowel) require preapproval.
- Facility-based care (SNF, LTAC, rehabilitation facility admissions) and other specified facility services.
- Bariatric surgery and other treatments for clinically severe obesity.
- Specialty pharmacy medications — managed by CarelonRx; see Pharmacy Clinical Criteria for requirements.
Denial Risk for Non‑Authorized Services
Denial risk for non-authorized services. Failure to obtain the required preapproval or prior authorization may result in denial of benefits or reduced member responsibility. Services not precertified may be subject to claim denials or member financial liability. Examples include non-authorized inpatient admissions, facility-based care, transplant inpatient admits, major surgical procedures listed on the Precertification List, and specialty drug therapies managed through CarelonRx.
- Anthem may deny coverage or reduce benefits if precertification is not obtained for inpatient admissions (elective and emergency) and other listed services.
- Lack of prior authorization for transplant inpatient admits may lead to denied benefits — contact Transplant Unit as instructed.
- Post-service claim edits may still apply for services recommended for predetermination of medical necessity even if precertification is not strictly required.
Transplant Unit Contact Required
Transplant contact requirement. For all transplant-related inpatient admits listed on the Precertification/Prior Authorization List, contact Anthem's Transplant Unit to initiate authorization and coordination of care. The Transplant Unit must be contacted as part of the preapproval process for listed transplant types.
- Contact Transplant Unit at 888-574-7215 for transplant inpatient admits.
- Transplant inpatient admits requiring contact include hand, heart, kidney, liver, lung (including double lung), multi‑visceral, pancreas, simultaneous pancreas/kidney, small bowel, and others listed.
- Stem cell/bone marrow transplant, uterine transplantation, tissue transplant and related outpatient and donor services also appear on the transplant-managed lists and may require authorization or coordination.
Policy Purpose and Background
Preapproval (also called precertification or prior authorization) is a utilization management process used to determine whether selected inpatient and outpatient services meet the plan’s medical necessity criteria and to ensure services are delivered in the appropriate setting. The process applies to services listed on the Precertification/Prior Authorization List and services managed through vendor programs (for example, Carelon/CarelonRx) and is intended to align coverage with the member’s benefits contract and avoid unexpected charges or denials.
Definitions and Applicability Exceptions
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