CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Connecticut Precertification/Prior Authorization List

This document lists services requiring precertification/prior authorization for Anthem Blue Cross and Blue Shield commercial plans in Connecticut and explains responsibilities and contact methods for providers and members.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyConnecticut Precertification/Prior Authorization List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProviders must contact Utilization Management to obtain precertification/prior authorization; requests must come from the provider or facility performing the service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1state-specific list (CT)

800-238-2227UM contact

866-714-1107Carelon contact

800-934-0331Behavioral Health

888-574-7215Transplant unit

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Services requiring precertification/prior authorization

Selected services and the responsible party for prior authorization or site-of-care review include (non-exhaustive):

ALL of the following

Anthem-responsible services
- Ablative techniques as a treatment for Barrett's Esophagus (Responsible party = Anthem).
- Ambulance services: air and water (Responsible party = Anthem).
- Behavioral health facility-based care (inpatient admissions, residential care) and related services (Responsible party = Anthem) — contact Behavioral Health at 800-934-0331.
- Biofeedback and neurofeedback (Responsible party = Anthem).
- Blepharoplasty, blepharoptosis repair, and brow lift (Responsible party = Anthem).
- Catheter-based embolization procedures for malignant lesions outside the liver (Responsible party = Anthem).
- Cochlear implants and auditory brainstem implants (Responsible party = Anthem).
- Cooling devices and combined cooling/heating devices (Responsible party = Anthem).
- Cosmetic and reconstructive procedures of the skin, head, neck, trunk, groin, and extremities (Responsible party = Anthem).
- Cryosurgical, radiofrequency, microwave, or laser ablation to treat solid tumors outside the liver (Responsible party = Anthem).
- Deep brain, cortical, and cerebellar stimulation (Responsible party = Anthem).
- Diaphragmatic/phrenic nerve stimulation and diaphragm pacing systems (Responsible party = Anthem).
- Durable medical equipment (Responsible party = Anthem).
- Gene therapy for select conditions (Responsible party = Anthem).
- Home parenteral nutrition (Responsible party = Anthem).
- Hyperbaric oxygen therapy (systemic/topical) (Responsible party = Anthem).
- Hysterectomy (Responsible party = Anthem).
- Implantable peripheral nerve stimulation devices for pain (Responsible party = Anthem).
- Infertility treatment (Responsible party = Anthem).
- Inpatient admissions (elective and emergency) — Anthem must be notified within 48 hours or two business days (Responsible party = Anthem).
- Selected surgery examples (breast procedures including reconstructive surgery and implants, cranial/facial surgery, nasal/sinus surgery, panniculectomy and abdominoplasty, partial left ventriculectomy, penile prosthesis implantation, scoliosis surgery, temporomandibular disorders, treatment of varicose veins, uterine fibroid ablation) (Responsible party = Anthem).
- Selected blood, serum, and cellular allergy and toxicity tests (Responsible party = Anthem).
- Orthotics and prosthetics (Responsible party = Anthem).
- Out-of-network referrals/services (Responsible party = Anthem).
- Private duty nursing in the home setting (Responsible party = Anthem).
- Stem cell/bone marrow transplant (with or without myeloablative therapy) and donor leukocyte infusion (Responsible party = Anthem) — contact Anthem transplant unit at 888-574-7215.
- Therapeutic apheresis (Responsible party = Anthem).
- Wearable cardioverter defibrillators (Responsible party = Anthem).
Carelon Medical Benefits Management-responsible services
- Bariatrics (Responsible party = Carelon Medical Benefits Management or Anthem).
- Base surgical (Responsible party = Carelon Medical Benefits Management).
- Cardiovascular services including arterial ultrasound, cardiac catheterization, cardiac devices, coronary angiography, noninvasive diagnostic vascular studies, and percutaneous coronary intervention (PCI) (Responsible party = Carelon Medical Benefits Management).
- Certain outpatient utilization management services (Responsible party = Carelon Medical Benefits Management).
- Echocardiology services including stress echocardiography, transesophageal echocardiography, and resting transthoracic echocardiography (Responsible party = Carelon Medical Benefits Management).
CarelonRx-responsible services
- Specialty pharmacy medications (Responsible party = CarelonRx, Inc.).

Notes: Providers should obtain precertification/prior authorization from the responsible utilization management entity. For HMO plans the participating provider must request precertification; for PPO plans, providers and members share responsibility. Prior authorization requests and site-of-care reviews are conducted by Carelon Medical Benefits Management and can be accessed via provider portals or by calling the Carelon contact center.

Provider and Member Responsibilities for Precertification

Prior Authorization

Provider responsibility for precertification (HMO)

For HMO plans: Participating providers must obtain precertification/prior authorization from the health plan's Utilization Management Department before rendering services. The request must come from the participating physician or the facility providing the service (not the referring physician), except where specific services allow otherwise. If precertification/prior authorization is not obtained, claim payment may be reduced or deemed ineligible for reimbursement and the member must be held harmless.

Prior Authorization

Precertification for PPO plans

For PPO plans: Both network providers and members share responsibility for precertification/prior authorization. Network care providers are responsible for obtaining precertification/prior authorization for services they provide; members are also responsible for obtaining precertification where required. Members are financially responsible for services and settings not covered under the certificate due to adverse determinations (e.g., not medically necessary or investigational). Contact the Utilization Management Department to obtain precertification at 800-238-2227 (the precertification number is also listed on the back of the member's ID card).

Note

How to request prior authorization

How to request prior authorization: Care providers may request prior authorization/preservice clinical review/medical necessity review through Carelon Medical Benefits Management, Inc., the independent vendor providing utilization management services for the plan. Options include: access Carelon's providerportal.com (available 24/7) for real-time requests; access via Availity (https://Availity.com); or call Carelon's Contact Center at 866-714-1107, Monday–Friday, 8 a.m.–5 p.m.

Vendor Definitions

Carelon Medical Benefits Management — definition / short descriptor

Legal/organizational nameCarelon Medical Benefits Management, Inc.

RoleIndependent company providing utilization management services on behalf of the health plan.

Services providedPrior authorization / preservice clinical review / medical necessity reviews; site-of-care review for select surgical services.

Access methodsProviderPortal (24/7), Availity, or Contact Center at 866-714-1107 (M–F, 8 a.m.–5 p.m.).

Decision basisUM decisions are based only on appropriateness of care and existence of coverage; reviewers are not incentivized to deny care.

CarelonRx — definition / short descriptor

Legal/organizational nameCarelonRx, Inc.

RoleIndependent company providing pharmacy benefit management services on behalf of the health plan.

Relationship to UMDistinct from Carelon Medical Benefits Management; supports pharmacy benefit management rather than utilization management for medical services.

OpenPayer

Connecticut Precertification/Prior Authorization List

Services Requiring Precertification / Prior Authorization

Example Listed Service / Codes

Provider and Member Responsibilities for Precertification

Vendor Definitions