Were glad youre interested in joining the Anthem network. You can also visit, Do Not Sell or Share My Personal Information. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. 2022 Anthem Dental and Vision Individual Enrollment Application for California. The resources for our providers may differ between states. Serving Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. Pharmacy Claim Form Note: this form is only to be used if you are on the Anthem HMO or HSA plans. Please Select Your State The resources on this page are specific to your state. <>/Metadata 157 0 R/ViewerPreferences 158 0 R>> Also, specify any allergies and give the name and phone number of the patients authorized representative (if applicable). stream Looking for a form that isnt listed? WebFind a Form; Dental Online Services; Login; Registration; Statement of Benefits (SOB) Summary of Benefits and Coverage (SBC) Providers. , or visit the Ohio Department of Medicaid's site. Physical health: 877-643-0671. It looks like you're in . Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Once an account has been created, providers can securely access Medicaid's enterprise systems. You can also refer to the provider manual for information about services that require prior authorization. Forms Please update your browser if the service fails to run our website. By filling out the form completely and with as much information as possible, you can be sure 2 0 obj To request or check the status of a prior authorization request or decision for a particular plan member, access our Interactive Care Reviewer (ICR) tool via Availity. Authorization Step 9 At the top of page 2, provide the patients name and ID number. You can also submit your request online through Availity:* https://mediproviders.anthem.com/nv/pages/home.aspx. stream Anthem Managed long-term services and supports requests for review of long-term care may be submitted using the provider website or via fax to 844-285-1167. WebPrecertification Requirements. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark. WebProvider Forms | KY Provider - Anthem Forms A library of the forms most frequently used by healthcare professionals. Retail pharmacy fax: 844-512-7020 Medical Authorization Below that, write the name of the requester (if different than the prescriber) and supply the prescribers NPI number and DEA number. WebFax: 1-800-754-4708 Behavioral Health: For prior authorization requests specific to behavioral health, please fax requests to 1-855-473-7902 or email Medi-calBHUM@wellpoint.com. WebForms. The resources for our providers may differ between states. Utilization Management (UM) for Major Risk Medical Insurance Program (MRMIP) Phone: 1-877-273-4193 Hours: Monday to Friday, 8 a.m. to 5 p.m. Fax: 1 Step 1 At the top of the form, supply the plan/medical group name, plan/medical group phone number, and plan/medical group fax number. 2022 California Individual ACA Plan Change Form. WebInpatient authorization fax information. Transition Assistance Form. Forms Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Medi-Cal Managed Care and Major Risk Medical Insurance Program Provider Manual. Forms Pharmacy Claim Form Note: this form is only to be used if you are on the Anthem HMO or HSA plans. For a full list of forms, visit Anthem's website: anthem.com/ca/forms. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patients prescription cost. Forms You can apply for Medicaid at any time. A library of the forms most frequently used by health care professionals. During this time, you can still find all The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem does not require prior authorization for treatment of emergency medical conditions. WebAnthem is a registered trademark of Anthem Insurance Companies, Inc. ANVPEC-1497-20 December 2020 Please check the appropriate box below and send only the corresponding authorization type to that fax number. AetnaBetterHealth.com/OhioRISE, or via phone. Providers will have the choice of using either Availity Essentials* or fax to submit prior authorization requests for all medical (non-pharmacy) services. You can also visit bcbs.com to find resources for other states It looks like you're outside the United States. 2022 Legacy Application Change Form for CA. Pharmacy Prior Authorization Form Anthem Blue Cross and Blue Shield (Anthem) recommends submitting precertification requests via Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity. Step 3 In Insurance Information, provide the primary and secondary insurance providersalong with the corresponding patient ID numbers. To check the status of a prior authorization request or decision for a particular plan member, or to submit a clinical appeal, providers will access our Interactive Care Reviewer (ICR) tool via Availity Essentials. WebFax: 1-800-754-4708 Behavioral Health: For prior authorization requests specific to behavioral health, please fax requests to 1-855-473-7902 or email Medi-calBHUM@wellpoint.com. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. To request or check the status of a prior authorization request or decision for a particular plan member, access our Interactive Care Reviewer (ICR) tool via Availity. Includes concurrent reviews for inpatient and admission request for skilled nursing facility, long term acute care, acute rehab, and nursing facilities; Behavioral health: 866-577-2184; Medicaid prior authorization: 800-964-3627. If yes, provide the medication name, dosage, duration of therapy, and outcome. s=~g0 _]gy66y2?64RTJY3)U&)yR=+2VScv;JIB_/O>/5}8xFFM>? All rights reserved. Physical health: 877-643-0671. Forms Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc. endobj Prior-Authorization %PDF-1.5 Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Interactive Care Reviewer Applications & Enrollments. Long-Term Care Authorization Request Form <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S>> Behavioral Health Claims & Billing Disease Management Maternal Child Services Other Forms Patient Care Precertification Provider tools & resources Request Some states cover any person who meets certain income requirements. Children. WebLong-Term Care Authorization Request Form This communication applies to Medicaid and Medicare Advantage plans from Anthem Blue Cross (Anthem). Please contactyourproviderrepresentative for assistance. WebProvider Forms | KY Provider - Anthem Forms A library of the forms most frequently used by healthcare professionals. WebMedical Prior Authorization Request Form Outpatient fax: 800-964-3627 LTSS fax: 844-864-7853 Expedited fax: 888-235-8390 Long-term Services and Supports Authorization Guide Pharmacy requests Visit our Pharmacy Information page for formulary information and pharmacy prior authorization forms. Screening, Brief Intervention, and Referral to Treatment, Early and Periodic Screening, Diagnostic and Treatment, Urine Drug Testing Prior Authorization Form, Substance Use Disorder Services Prior Authorization Form, Includes concurrent reviews for inpatient and admission request for skilled nursing facility, long term acute care, acute rehab, and nursing facilities, Includes precertifications for elective admissions, Includes home healthcare, high dollar imaging, physical therapy, occupational therapy, speech therapy, per diem nursing, durable medical equipment, chiropractic, and acupuncture, Provide expert clinical knowledge to establish, Contract with pharmacies to ensure members have easier access to medications. Anthem Blue Cross and Blue Shield member site. Authorization 2023 Anthem Dental Individual Enrollment Application for California. 2q^o}|"(2>|! The resources for our providers may differ between states. The formcontains important information regarding the patients medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patients health care plan. An Anthem(Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patients prescription cost. WebWeve provided the following resources to help you understand Anthems prior authorization process and obtain authorization for your patients when its required. By filling out the form completely and with as much information as possible, you can be sure ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. People with disabilities. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Anthem Blue Cross Card Dispute Form. WebAnthem Blue Cross and Blue Shield Pharmacy Prior Authorization Form Page 2 of 3 Medication information Drug name and strength requested: SIG (dose, frequency and duration): HCPCS billing code: Diagnosis and/or indication: ICD-10 code: Has the member tried other medications to treat this condition? Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2023. Applications & Enrollments. WebEasily find and download forms, guides, and other related documentation that you need to do business with Anthem all in one convenient location! We currently don't offer resources in your area, but you can select an option below to see information for that state. In the event of an emergency, members may access emergency services 24/7. The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization/precertification form at anthem.com/medicareprovider > Providers > Provider Resources > Forms and Guides. Precertification Forms Sydney Health is offered through an arrangement with Carelon Digital Platforms, a separate company offering mobile application services on behalf of your health plan. Anthem <> If you receive care from a doctor orhealthcare provider not in your plans network, your share of the costs may be higher. Authorization Card Dispute Form. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patients prescription cost. Serving California. Debit Cardholder Agreement. During this time, you can still find all endobj Forms Select a state for information that's relevant to you. %PDF-1.7 WebDebit Cardholder Agreement & Dispute Form. You can also submit your request online through Availity:* https://mediproviders.anthem.com/nv/pages/home.aspx. Type at least three letters and we will start finding suggestions for you. Managed long-term services and supports requests for review of long-term care may be submitted using the provider website or via fax to 844-285-1167. 4 0 obj Type at least three letters and we will start finding suggestions for you. We currently don't offer resources in your area, but you can select an option below to see information for that state. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. OhioRISE (Resilience through Integrated Systems and Excellence) is a specialized managed care program for youth with behavioral health and multi-system needs. Independent licensees of the Blue Cross Association. Anthem Blue Cross and Blue Shield Member Site. endobj ODM has contracted with a single pharmacy benefit manager (SPBM) to improve the administration of pharmacy benefits for managed care recipients and ensure transparency, accountability, and integrity to better serve Ohio Medicaid members and their healthcare providers. You can also visit bcbs.com to find resources for other states It looks like you're outside the United States. <> People with disabilities. ICR offers a fast, efficient way to securely submit your requests with clinical documentation. Do not sell or share my personal information. Forms Retail pharmacy fax: 844-512-7020 Medical Pharmacy Claim Form Note: this form is only to be used if you are on the Anthem HMO or HSA plans. WebANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Aetna Better Health of Ohio will serve as the single statewide specialized managed care plan. Forms By using the website, you agree to our use of cookies to analyze website traffic and improve your experience on our website. 2023 Anthem Dental Individual Enrollment Application for California. Anthem Independent licensees of the Blue Cross Association. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Authorization Pharmacy benefits for enrolled members are managed through the Ohio Department of Medicaid (ODM). Yes. Medical Claim Form. Feel free to contact ProviderServices for assistance. If your state isn't listed, check out bcbs.com to find coverage in your area. Step 10 On page 2 (1), select yes or no to indicate whether the patient has tried other medications for their condition. Transition Assistance Form. The SPBM provides more pharmacy choices for members and offers a more streamlined process for providers with a single preferred drug list and uniform clinical criteria for coverage. WebFamilies. We look forward to working with you to provide quality services to our members. Prior Authorizations Claims & Billing Behavioral Health Patient Care Clinical Pregnancy and Maternal Child Services For Providers WebInteractive Care Reviewer (ICR) is Anthems innovative utilization management (UM) portal that allows health care professionals to submit prior authorization requests and clinical information and receive status updates without having to WebEasily find and download forms, guides, and other related documentation that you need to do business with Anthem all in one convenient location! Type at least three letters and well start finding suggestions for you. Feel free to contact Provider Services for assistance. In the event that the emergency room visit results in the members admission to the hospital, providers must contact Anthem within one business day following admission or post-stabilization. Provider Forms WebInteractive Care Reviewer (ICR) is Anthems innovative utilization management (UM) portal that allows health care professionals to submit prior authorization requests and clinical information and receive status updates without having to Our Interactive Care Reviewer (ICR) tool via Availity is the preferred method for submitting prior authorization requests, offering a streamlined and efficient experience for providers requesting inpatient and outpatient medical or behavioral health services for our members. Providers can create an Ohio Identification (OH|ID) account through the state's login system at any time. Our forms are organized by state. You can apply for Medicaid at any time. Utilization Management (UM) for Major Risk Medical Insurance Program (MRMIP) Phone: 1-877-273-4193 Hours: Monday to Friday, 8 a.m. to 5 p.m. Fax: 1 2021 copyright of Anthem Insurance Companies, Inc. Anthem Blue Cross and Blue Shield is the trade name of Compcare Health Services Insurance Corporation, an independent licensee of the Blue Cross and Blue Shield Association. Your browser is not supported. We currently don't offer resources in your area, but you can select an option below to see information for that state. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). authorization