CurrentBlue Cross Blue Shield - NevadaPolicy MULTI-BCBS-CM-002316-25-S852

Anthem National Accounts standard prior authorization requirements

Lists services and categories that require preauthorization or precertification for Anthem National Accounts commercial plans; applies to providers submitting claims for Anthem National Accounts members and to vendor-managed programs.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyAnthem National Accounts standard prior authorization requirements

Policy CodePolicy MULTI-BCBS-CM-002316-25-S852

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify member eligibility and whether preapproval is needed by calling the number on the member ID or contacting Carelon for vendor-managed programs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20+service categories listed

CarelonCarelon manages programs

Not requiredEmergency admissions

PossibleNOC/unlisted code review

Coverage and Precertification Rules

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Coverage and precertification criteria

Preapproval and coverage determinations depend on the member's eligibility and specific plan benefits; verify using the member ID or Carelon for vendor-managed programs.

ALL of the following

Verify by
- Call the phone number on the back of the member's identification card to confirm eligibility, covered benefits, and whether preapproval is required.
- Verify eligibility and benefits via the Anthem website or provider portal.
If the service or code is managed by Carelon, call Carelon Medical Benefits Management at 866-714-1103 (Mon–Fri, 8 a.m. to 6 p.m. ET) or follow Carelon site instructions to determine if preapproval is needed.

ALL of the following

For codes/programs noted as managed by Carelon, the precertification requirement applies only to vendor program–eligible members.
Carelon manages specialty programs including cardiovascular services, diagnostic imaging management, genetic testing, imaging level of care, musculoskeletal (MSK), oncology drugs, and outpatient sleep testing and therapy services; confirm member eligibility for these vendor programs before submitting precertification requests.

ALL of the following

When service requires precertification
- If the member's benefit covers the service and the service is listed in this policy, precertification is required prior to the service (examples include inpatient admissions, specified diagnostic testing, DME/prosthetics, gender-affirming surgery when covered, transplants/CAR T-cell/gene therapies, MHSA services, numerous outpatient/surgical procedures, radiation/radiology services).
When precertification is not required
- If the service is excluded by the employer group or the member's benefit does not cover the service, precertification is not applicable.
- For emergency admissions, precertification is not required; however, plan notification should be provided as soon as possible.

ALL of the following

NOC/unlisted codes may be reviewed upon claim submission depending on diagnosis and reimbursement level; verify whether precertification was required for billed codes.
Providers are responsible for verifying member eligibility and covered benefits at the time the service is reviewed/approved; benefit plans and contract effective dates may affect coverage determinations.

ALL of the following

Because National Accounts may have employer-specific customization, always confirm any customized precertification approach with the Provider Services number on the member's ID card.
When services have medical necessity criteria determined by corporate Medical Policy or adopted Clinical Guidelines, consider pre-determination even if precertification is not strictly required because post-service claim edits or high member financial exposure may apply.

Provider Actions and Prior Authorization Requirements

Prior Authorization

Inpatient admissions prior authorization

Precertification is required for the listed inpatient admissions when the benefit is covered. For emergency admissions, precertification is not required but the plan should be notified as soon as possible.

Acute inpatient
Acute rehabilitation
Long-term acute care hospital (LTACH)
Skilled nursing facility
OB delivery stays beyond the federal mandate minimum length of stay (including newborn stays beyond the mother's stay)

Prior Authorization

Diagnostic testing prior authorization

Precertification is required for specified diagnostic testing when the benefit is covered. Some tests are managed by vendor programs (Carelon) — verify member-specific program eligibility before submission.

Breast cancer (BRCA) genetic testing
Chromosomal microarray analysis (CMA) for developmental delay, autism spectrum disorder, intellectual disability, and congenital anomalies
Gene expression profiling for breast cancer management
Gene mutation testing for cancer susceptibility and management
Genetic testing for inherited diseases (including Lynch syndrome, FAP, attenuated FAP, MYH-associated polyposis)
Testing for biochemical markers for Alzheimer's disease
Whole genome sequencing, whole exome sequencing, gene panels, and molecular profiling
Wireless capsule endoscopy (including patency capsule) for gastrointestinal imaging and motility disorders
Preimplantation embryo biopsy
Prostate saturation biopsy
Per- and polyfluoroalkyl substances (PFAS) testing

Prior Authorization

DME / prosthetics prior authorization

Precertification is required for listed durable medical equipment and prosthetic devices when the benefit is covered.

Augmentative and alternative communication (AAC) devices with digitized or synthesized speech output
Brain-computer interface rehabilitation devices
Compression devices for lymphedema
Electric tumor treatment field (TTF) devices
External upper limb stimulation for tremor treatment
Functional electrical stimulation (FES); threshold electrical stimulation (TES)
High-frequency chest compression devices for airway clearance
Home video-assisted robotic rehabilitation systems
Implantable infusion pumps
Intrapulmonary percussive ventilation devices
Microprocessor-controlled knee-ankle-foot orthosis
Microprocessor-controlled lower limb prosthesis
Myoelectric upper extremity prosthetic devices
Neuromuscular electrical training for obstructive sleep apnea/snoring
Noninvasive electrical bone growth stimulation of the appendicular skeleton
Robotic arm assistive devices

Prior Authorization

Gender‑affirming surgery prior authorization

If gender-affirming surgery is a covered benefit under the member's plan, pre-certification is required prior to the procedure.

Prior Authorization

Transplant and cell / gene therapy prior authorization

Precertification is required for inpatient admits for all solid organ and bone marrow/stem cell transplants and for many transplant-related outpatient procedures. Pre-certification is also required for CAR T-cell therapies and for covered gene replacement or gene therapies.

Inpatient admissions for solid organ and bone marrow/stem cell transplants (including kidney-only transplants)
Outpatient transplant or transplant-related procedures (e.g., donor leukocyte infusion, intrathecal SMA treatments like nusinersen when applicable, stem cell/bone marrow transplant with or without myeloablative therapy, allogeneic bone marrow-derived mesenchymal stromal cell therapy)
CAR T-cell immunotherapies (examples include Yescarta, Kymriah, Breyanzi, Abecma, Tecartus, Carvykti, and others)
Gene replacement and gene therapies (if covered, pre-certification required; examples include Zolgensma, Luxturna, ZYNTEGLO, and listed investigational/approved gene therapies)

Prior Authorization

Mental health / substance abuse prior authorization

Precertification is required or recommended for behavioral health and substance abuse services as specified. Check the member's benefits for any exclusions or group-specific requirements.

Acute inpatient mental health/substance abuse admissions
Residential care
Transcranial magnetic stimulation (TMS)
Behavioral health in‑home programs
Applied behavioral analysis (ABA) — precertification recommended and applies unless the group opts out of clinical review; retrospective review allowed
Intensive outpatient program (IOP) — check benefits for precertification requirements
Partial hospitalization program (PHP) — check benefits for precertification requirements

Prior Authorization

Other outpatient and surgical services prior authorization

Precertification is required for a broad range of outpatient and surgical services when the benefit is covered. For certain services the requirement applies only if the group offers the benefit — verify member-specific coverage.

Bariatric surgery and other treatments for clinically severe obesity (pre-certification required if benefit is covered)
Selected complex surgeries and devices (e.g., cardiac contractility modulation, CRT/ICD, ventricular assist devices, leadless pacemaker, mechanical circulatory assist devices)
Advanced implantable devices (e.g., cochlear implants, implantable spinal cord stimulators, penile prosthesis, implanted artificial iris, implanted infusion pumps)
Cellular and other advanced therapies (e.g., Sipuleucel-T, cellular therapy products for allogeneic stem cell transplantation)
Numerous specialty procedures (examples include axillary lumbar interbody fusion, functional endoscopic sinus surgery, focal laser ablation for prostate cancer, transcatheter heart valve procedures, minimally invasive treatments for rhinitis, cochlear implants, keratoprosthesis)
Cosmetic and reconstructive procedures (various head/neck/trunk procedures)
Home parenteral nutrition and private duty nursing in the home setting
Hyperbaric oxygen therapy, therapeutic apheresis, and other specialty treatments

Prior Authorization

Radiation / radiology prior authorization

Precertification is required for radiation therapy and advanced radiology services when the benefit is covered.

Intensity modulated radiation therapy (IMRT)
Proton beam therapy
Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT)
Radioimmunotherapy and somatostatin receptor–targeted radiotherapy (e.g., Lutathera, Pluvicto, Azedra, Zevalin)
Catheter-based embolization procedures for malignant lesions outside the liver
Cryosurgical or radiofrequency ablation for solid tumors outside the liver
MRI-guided high-intensity focused ultrasound ablation (non-oncologic indications)
Wireless capsule endoscopy (GI imaging)
Xofigo (Radium Ra 223 Dichloride)

OpenPayer

Anthem National Accounts standard prior authorization requirements

Coverage and Precertification Rules

Codes Requiring Review on Claim

Provider Actions and Prior Authorization Requirements

Definitions and Vendor Details