CurrentBlue Cross Blue Shield - MainePolicy N/A

Maine Precertification/Prior Authorization List

A statewide list of services and procedures for which Anthem Blue Cross Blue Shield (Maine) requires precertification/prior authorization or utilization management review, specifying responsible parties (Anthem, Carelon Medical Benefits Management, CarelonRx, Behavioral Health) and contact details for authorization.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMaine Precertification/Prior Authorization List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from the named responsible party before providing listed services and ensure requests come from the rendering provider or facility.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or authorization requirements.

~70Listed service categories requiring prior authorization

MultipleResponsible parties

Coverage Summary

Scope: A statewide list of services and procedures for which Anthem Blue Cross Blue Shield (Maine) requires precertification/prior authorization or utilization management review, specifying responsible parties (Anthem, Carelon Medical Benefits Management, CarelonRx, Behavioral Health) and contact details for authorization.

Coverage stance: billing_rules — Precertification/prior authorization is required for selected inpatient and outpatient medical services and must be obtained prior to service to ensure coverage and avoid claim reduction or denial.

General Precertification/Prior Authorization Requirements

Precertification/prior authorization is required for selected inpatient and outpatient medical services and must be obtained prior to service to ensure coverage and avoid claim reduction or denial.

ALL of the following

Request for prior authorization must come from the care provider or facility rendering the service (not the referring physician), except where noted for specific services.
Member must be eligible for benefits and service must be a covered benefit under the contract at time of service and within benefit limits.
If prior authorization is not obtained, claim payment may be reduced or denied and the member must be held harmless (for participating providers).
For PPO-type plans, members may be responsible if nonparticipating provider did not obtain required authorization.
Anthem will provide a copy of the approval to the member and the physician or provider of service.
Concurrent review may adjust number of days authorized for inpatient care.

How to Request Authorization & Provider Responsibilities

How to Request Authorization

Options for requesting prior authorization and utilization management contact points.

ANY of the following

Call Anthem Utilization Management Department at 800-392-1016.
Access Carelon Medical Benefits Management ProviderPortalSM online for real-time authorization processing.
Access Carelon via Availity Web Portal at https://Availity.com.
Call Carelon Medical Benefits Management Contact Center toll-free 866-714-1107, Monday–Friday 8 a.m.–5 p.m.
Behavioral health prior authorization: Contact Behavioral Health, Inc at 800-755-0851.

Prior Authorization

Obtain prior authorization from the responsible party

Providers or facilities rendering listed services must obtain prior authorization from the named responsible party (Anthem, Carelon Medical Benefits Management, CarelonRx, or Behavioral Health) before providing the service; requests must originate from the rendering provider/facility.

Documentation Required

Verify member eligibility and benefits

Prior to requesting authorization, verify member eligibility, benefits, and account information using the member ID card phone number or designated portals; services are covered only if member is eligible and benefits exist at time of service.

Billing Rule

Potential claim denial or reduction without authorization

Claims for services requiring prior authorization may be reduced or denied if prior authorization is not obtained; for PPO-type plans, members may be financially responsible for services by nonparticipating providers without authorization.

Prior Authorization

Behavioral health prior authorization contact

Contact Behavioral Health, Inc at the number below for prior authorization of behavioral health services (inpatient behavioral health and substance abuse admissions, PHP, IOP, intensive in-home services, TMS, ABA).

800-755-0851

Prior Authorization

Transplant prior authorization contact

For transplant services and stem cell/bone marrow transplants contact the Transplant unit for prior authorization.

888-574-7215

Background

Precertification/prior authorization is Anthem's process to determine medical necessity for selected inpatient and outpatient services (including surgeries, major diagnostic procedures and referrals) to ensure the member receives maximum benefits, that care is provided in an appropriate network setting by an appropriate provider, and to help avoid unnecessary charges or penalties.

Requests for prior authorization must originate from the care provider or facility rendering the service (not the referring physician), and the member must be eligible for benefits and the service must be a covered benefit under the contract at the time of service and within benefit limits.

If prior authorization is not obtained, claim payment may be reduced or denied and, for PPO-type plans, the member may be financially responsible; participating providers must follow authorization requirements and members/providers will receive a copy of approvals.

This list is subject to change and is not all-inclusive.

Precertification/Prior Authorization: A determination by Anthem that selected services are medically necessary and must be authorized prior to being rendered for the member to receive maximum benefits.

Responsible party: The entity (Anthem, Carelon Medical Benefits Management, CarelonRx, Behavioral Health) designated to perform utilization management/prior authorization for a given service category.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMaine Precertification/Prior Authorization List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from the named responsible party before providing listed services and ensure requests come from the rendering provider or facility.

SourceLink

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OpenPayer

Maine Precertification/Prior Authorization List

Coverage Summary

How to Request Authorization & Provider Responsibilities

Responsible Party Assignments (Service Categories)

Coding

Background

Revision History