Prior authorization required for listed UM guideline services

Certain services listed in the adopted Clinical UM Guideline index require prior authorization; examples called out in the document include monitored anesthesia for gastrointestinal endoscopic procedures and upper gastrointestinal endoscopy, radiation therapy (including proton beam therapy and other radiation categories), select cardiology procedures (e.g., diagnostic coronary angiography, percutaneous coronary intervention, implantable devices, ablation, ambulatory cardiac rhythm monitoring), select imaging categories, and other guideline-specified services. Prior authorization review may be performed for select accounts using the Anthem Clinical UM Guidelines.

• Monitored Anesthesia Care for GI endoscopic procedures and upper GI endoscopy: CG-MED-34 and CG-MED-59 reference prior authorization and implementation dates.
• Radiation therapy categories (Radiation Therapy excluding Proton; Proton Beam Therapy) are listed with implementation dates and referenced Carelon radiation oncology guidelines.
• Cardiology procedures (Diagnostic Coronary Angiography, Percutaneous Coronary Intervention, Implantable Cardioverter Defibrillators, Permanent Implantable Pacemakers, Cardiac Resynchronization Therapy, various ablation procedures, Ambulatory Cardiac Rhythm Monitoring) appear in the guideline index and may be subject to prior authorization review for select accounts.

Drugs listed under CC- guidelines are managed by UM and may require step edits

Multiple drug-specific Clinical Guideline (CC-) entries are managed under the UM program and are subject to clinical review and prior authorization per their individual guidelines; these include agents such as Exondys 51 (eteplirsen), Spinraza (nusinersen), Krystexxa (pegloticase), growth hormone therapies, tumor necrosis factor antagonists, ustekinumab, interleukin inhibitors, hemophilia agents, and others.

• Each CC- guideline entry (e.g., CC-0044 Exondys 51; CC-0048 Spinraza; CC-0057 Krystexxa; CC-0068 Growth Hormone; CC-0062 Tumor Necrosis Factor Antagonists; CC-0063 Ustekinumab) indicates the drug is subject to UM review and prior authorization per that guideline.
• Drug management may include step edits or review processes as specified in the individual CC- guideline implementation entries.

Precertification notification and contact

When a provider requests precertification, the provider will be notified if precertification is required for the member; if the program has not been purchased for that member’s plan, precertification is not required and clinical review will not be performed. For more information, contact the phone number on the back of the member’s ID card.

• Notification occurs at the time the provider requests precertification.
• Contact information for precertification questions is the phone number on the member ID card.

Precertification and pre-payment review triggers

Claims may be reviewed or subject to pre-payment review if a provider’s billing practices are not consistent with peers or when Clinical Guidelines approved by MPTAC (but not included in the standard adopted list) are used for provider education; the determination for precertification is made when requesting precertification and prior authorization review may be performed for select accounts.

• Pre-payment review can be triggered by billing practice variance (frequency or other inconsistencies compared with peers).
• Guidelines approved by MPTAC but not in the adopted list may be used for provider education or to review claims for select purposes.
• Precertification requirement is determined at the time of the precertification request; select accounts may be subject to Anthem Clinical UM Guideline prior authorization review.