CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Anthem standard preapproval requirements

Defines Anthem/Anthem Blue Cross and Blue Shield preapproval requirements for specified outpatient and inpatient services for local fully insured Georgia members and select ASO members; excludes certain programs and other member types.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyAnthem standard preapproval requirements

Policy CodePolicy N/A

Change TypeMinor — no material changes

Effective DateFebruary 13, 2025

Next Review DateN/A

Key ActionSubmit preapproval requests via the Carelon Provider Portal (select GA) or call 866-714-1103; allow preferably 15 calendar days and at least 3 business days for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Pages

15+ daysRecommended lead time

3 daysMinimum review

866-714-1103Carelon phone

24 hrsNotify for admissions

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services requiring preapproval (sample list)

The following outpatient and some inpatient services require preapproval for applicable members. This list is non‑exhaustive as presented in the source document.

Services listed below require preapproval for applicable members (non‑exhaustive).

Sample services (not exhaustive)

Ablative Techniques as a Treatment for Barrett's Esophagus
Advanced Lipoprotein Testing
Wound Healing and Soft Tissue Grafting (Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products)
Antineoplaston Therapy
Aortic Aneurysm, Thoracic, Repair with Graft; Aortic Coarctation, Excision or Repair
Applied Behavioral Analysis for Autism Spectrum Disorder
Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
Artificial Retinal Devices
Automated Evacuation of Meibomian Gland
Automated Nerve Conduction Testing
Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Bicompartmental Knee Arthroplasty
Biofeedback and Neurofeedback
Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
Blepharoplasty, Blepharoptosis Repair and Brow Lift
Blood‑based Biomarker Tests for Multiple Sclerosis
Bone‑Anchored and Bone Conduction Hearing Aids
Bowel Surgery (including Abdominoperineal Resection, Total Colectomy with Proctectomy, Partial Colectomy with/without Ostomy, small intestine resection)
Breast Procedures including Reconstructive Surgery and Implants
Cardiac Contractility Modulation Therapy
Cardiac Resynchronization Therapy with/without ICD for Heart Failure
Cardiac Valve Replacement or Repair (including Ross Procedure)
Cardioverter‑Defibrillators
Carotid, Vertebral and Intracranial Artery Angioplasty with/without Stent
Carotid Sinus Baroreceptor Stimulation Devices
Catheter‑based Embolization Procedures for Malignant Lesions Outside the Liver
Cochlear Implants and Auditory Brainstem Implants
Circulating Tumor DNA Panel Testing (Liquid Biopsy)
Combined Pathogen Identification and Drug Resistance Testing
Cosmetic and Reconstructive Services (head/neck, trunk/groin/extremities, skin‑related)
Cryoablation for Plantar Fasciitis and Plantar Fibroma
Cryosurgical/Radiofrequency/Microwave/Laser Ablation to Treat Solid Tumors Outside the Liver
Detection of Circulating Tumor Cells
Deep Brain, Cortical, and Cerebellar Stimulation
Drug‑Eluting Devices for Maintaining Sinus Ostial Patency
Electrical Stimulation (surface and percutaneous) as a Treatment for Pain and Other Conditions
Electroencephalography and Video EEG Monitoring
Electronic Home Visual Field Monitoring
Electronic Positional Devices for Treatment of Obstructive Sleep Apnea
Electrophysiology‑Guided Noninvasive Stereotactic Cardiac Radioablation
Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
Endovascular/Endoluminal Repair of Aortic Aneurysms and Related Aortic Procedures
Epiduroscopy
External Upper Limb Stimulation for Treatment of Tremors
Extracorporeal Shock Wave Therapy
Low‑Frequency Ultrasound Therapy for Wound Management
Lower Esophageal Sphincter Augmentation Devices for GERD
Lung Volume Reduction Surgery
Machine Learning Derived Probability Score for Rapid Kidney Function Decline
Mandibular/Maxillary (Orthognathic) Surgery
Manipulation Under Anesthesia
Mastectomy/Axillary procedures including Gynecomastia procedures
Medical Specialty Drug Reviews (non‑oncology)
Metagenomic Sequencing for Infectious Disease (outpatient)
Microprocessor Controlled Knee‑Ankle‑Foot Orthosis and Lower Limb Prosthesis
Minimally Invasive Treatment of Posterior Nasal Nerve for Rhinitis
Molecular Signature Test for Predicting Response to TNF Inhibitor Therapy
MRI Guided High Intensity Focused Ultrasound Ablation for Non‑Oncologic Indications
Multi‑biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
Myocardial Strain Imaging and Sympathetic Innervation Imaging
Nanoparticle‑Mediated Thermal Ablation
Nasal Valve Repair
Near‑Infrared Spectroscopy Screening for Brain Hematoma Detection
Neuromuscular Electrical Training for Obstructive Sleep Apnea or Snoring
Neutron Beam Radiotherapy
Noninvasive Heart Failure and Arrhythmia Management and Monitoring Systems
Noninvasive Imaging Technologies for Evaluation of Skin Lesions
Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
Osseointegrated Limb Prostheses
Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
Pain Management Biomarker Analysis
Panniculectomy and Abdominoplasty
Paraesophageal Hernia Repair
Parenteral Antibiotics for Treatment of Lyme Disease
Partial Left Ventriculectomy
Patent Foramen Ovale and Left Atrial Appendage Closure Devices
Penile Prosthesis Implantation
Percutaneous Vertebral Disc Procedures
Pneumatic Compression Devices for DVT Prevention in Home Setting
Portable Normothermic Organ Perfusion Systems
Powered Robotic Lower Body Exoskeleton Devices
Powered Wheeled Mobility Devices
Presbyopia and Astigmatism‑Correcting Intraocular Lenses
Private Duty Nursing in the Home Setting
Proprietary Algorithms for Liver Fibrosis
Prostate Saturation Biopsy
Protein Biomarkers for Prostate Cancer Screening/Detection/Management
Quantitative Sensory Testing
Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
Radiostereometric Analysis (RSA)
Reduction Mammaplasty
Renal Sympathetic Nerve Ablation
Sacral Nerve Stimulation for Neurogenic Bladder Secondary to Spinal Cord Injury
Scoliosis Surgery
Selected Blood, Serum and Cellular Allergy and Toxicity Tests
Selected Protein Biomarker Algorithmic Assays
Selected Sleep Testing Services
Self‑Expanding Absorptive Sinus Ostial Dilation
Sensory Stimulation for Brain‑Injured Individuals in Coma/Vegetative State
Septoplasty
Serologic Testing for Biomarkers of IBS
Serum Biomarker Tests for Risk of Preeclampsia
Surface Electromyography and Electrodermal Activity
Sensor Devices for Seizure Monitoring
Static Progressive Stretch (SPS) and PASS Devices
Surgical and Ablative Treatments for Chronic Headaches
Testing for Biochemical Markers for Alzheimer’s Disease
Therapeutic Apheresis
Therapeutic use of Stem Cells, Blood and Bone Marrow Products
Total Ankle Replacement
Transcatheter Heart Valve Procedures
Transcatheter Uterine Artery Embolization
Transcranial Magnetic Stimulation
Transendoscopic Therapy for GERD, Dysphagia and Gastroparesis
Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
Transmyocardial Revascularization
Treatment of Varicose Veins (Lower Extremities)
Treatments for Urinary Incontinence
Tropism Testing for HIV Management
Ultrafiltration in Decompensated Heart Failure
Ultrasound Bone Growth Stimulation
Uterine Fibroid Ablation (laparoscopic, percutaneous, transcervical image‑guided)
Vagus Nerve Stimulation
Vein Embolization for Pelvic Congestion Syndrome and Varicocele
Venous Angioplasty with/without Stent or Venous Stenting Alone
Viscocanalostomy and Canaloplasty
Wearable Cardioverter Defibrillators
Wireless Capsule for Evaluation of Suspected Gastric and Intestinal Motility Disorders
Wireless Left Ventricular Pacing for Cardiac Resynchronization Therapy

HMO/POS/PPO rules

Plan‑type specific rules and consequences if required preapproval is not obtained.

Services listed in this policy require preapproval; consequences vary by plan type as described below.

ANY of the following

HMO: Services listed require preapproval and will not be approved if rendered without the appropriate preapproval regardless of whether they are rendered in or out of network. HMO members do not have benefits for non‑emergency services rendered outside of the network without obtaining a preapproval.
POS: Services listed require preapproval and will not be approved if rendered without the appropriate preapproval regardless of whether they are rendered in or out‑of‑network. Providers must have a referral for in‑network benefit payment (except Blue Direct specialists and Open Access providers performing services that no longer require preapproval). If there is no referral or the member self‑referred, the out‑of‑network benefit level will be paid.

Submission, Eligibility, and Notification Requirements

Prior Authorization

Preapproval submission and notification process

Submit all required clinical information preferably 15 calendar days before the proposed procedure; allow a minimum of 3 business days for a complete clinical review. Institutional admissions must notify Anthem within 24 hours or the next business day after admission. For Georgia members, submit requests via the Carelon Provider Portal (select GA) or call Carelon at 866-714-1103, Monday–Friday 8 a.m.–6 p.m. ET.

Minimum 3 business days required for clinical analysis
Submit requests via Carelon Provider Portal (select GA) or call 866-714-1103, Mon–Fri 8am–6pm ET

Denial Risk

Who requires preapproval and consequences for lack of preapproval

Preapproval requirements apply to local, fully insured Anthem members in Georgia and select self‑insured (ASO) members for the services listed in this policy. These requirements do not apply to BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program (FEP) members. Failure to obtain required preapproval may result in services not being approved or reimbursement issues per plan type (HMO/POS/PPO rules).

Applies to local fully insured Georgia members and select ASO members
Excludes BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, and FEP members
HMO/POS/PPO plan rules: services require preapproval and may be denied or paid at different benefit levels if rendered without preapproval

Documentation Required

Verify eligibility and benefits before requesting preapproval

Verify member eligibility and benefits through the Anthem website or by calling the number on the back of the member’s ID card. Preapproval decisions are based on the member’s benefit plan and eligibility at the time the service is reviewed; providers are responsible for verifying eligibility and covered benefits.

Eligibility and benefits verification via website or phone
Preapproval is determined by benefit plan and member eligibility at time of review
Providers are responsible for verification of member eligibility

OpenPayer

Anthem standard preapproval requirements

Services That Require Preapproval

Code Handling and Turnaround

Submission, Eligibility, and Notification Requirements

Key Definitions and Applicable Populations