Authorization Program
The Authorization Program provides prior authorization for medical care or service from a non-network provider and for certain "special services." It is your responsibility to obtain authorization before you receive any service subject to the Authorization Program. Call Anthem Blue Cross' pre-authorization and pre-service review toll-free number at 800-274-7767, which is printed on your ID card.
If you receive any such service and do not follow the procedures outlined in this section, your benefits will be reduced as shown under "Effects on Benefits" under "Utilization Review Program."
Services Requiring Authorization
Authorized Referrals
In order for the maximum benefits of the Plan to be payable, advance authorization is required for services received from non-network providers. When the appropriate authorization is obtained, these services are called "authorized referral services."
Note: Authorized referrals are not required for the services of physicians of a type not available within the Prudent Buyer Plan PPO network (for example, an audiologist). A physician's written referral is required, however, in order for the services of some physicians to be covered under the Plan.
Special Services
Pre-authorization is also required to obtain benefits for:
*A $300 penalty is assessed if pre-authorization is not obtained.
Effect on Benefits
Authorized Referrals
  • For services requiring an Authorized Referral, the copayment for network providers will apply for medically necessary and appropriate authorized referral services received from a non-network provider.
  • The coinsurance for non-network providers will apply for referral services received from non-network providers that have not been authorized in advance.
Special Services
  • A $300 penalty is assessed if pre-authorization is not obtained for the following special services received from either network or non-network providers: skilled nursing facility admissions; home health care; hospice or home hospice care; or the purchase or cumulative rental of durable medical equipment equal to or over $1,000.
When Authorization Will Be Provided
Authorized Referrals
Referrals to non-network providers will be authorized only when all of the following criteria are met:
  • There is not a network provider within a 30-mile radius of your residence who:
    • Practices the appropriate specialty, or
    • Provides the required services, or
    • Has the necessary facilities;
  • You are referred to the non-network provider by a physician who is a network provider; and
  • The services are authorized as medically necessary before services are received.
Special Services
Organ and Tissue Transplants
  • Authorizations for organ and tissue transplants will be provided as follows:
    • For kidney or cornea transplants, both of the following criteria must be met:
      • The services are medically necessary and appropriate; and
      • The physicians on the surgical team and the facility in which the transplant is to take place are approved for the transplant requested.
    • For transplantation of liver, heart, heart-lung, lung, kidney-pancreas or bone marrow, including autologous bone marrow transplant, peripheral stem cell replacement and similar procedures, both of the following criteria must be met:
      • The services are medically necessary and appropriate; and
      • The providers of related pre-operative and post-operative services are approved.
Note: Organ and Tissue Transplants are only covered in-network. Coverage for transplants done at a network facility but not at a Center of Medical Excellence (CME) is 70%. See "Organ and Tissue Transplants" for more details.
Transplant Travel Expense Benefits
  • Authorizations for transplant travel expense benefits will be provided for the recipient and one companion (up to two companions if the transplant recipient is a child) only if all of the following criteria are met:
    • The procedure is for transplantation of liver, heart, heart-lung, lung, kidney-pancreas, kidney, cornea, or bone marrow, including autologous bone marrow transplant, peripheral stem cell replacement and similar procedures, and authorized by Anthem Blue Cross;
    • The organ transplant is performed at a specific Center of Medical Excellence (CME) or at a pre-authorized participating kidney or cornea transplant facility; and
    • The specific CME is 50 miles or more from the recipient's home.
Home Health Care
    • Authorizations for home health care services will be provided only if all of the following criteria are met:
      • The services are medically necessary and appropriate and can be safely provided in the beneficiary's home, as certified by the attending physician;
      • The attending physician manages and directs the beneficiary's medical care at home; and
      • The attending physician must establish a definitive treatment plan which must be consistent with the beneficiary's medical needs and must list the services to be provided by the home health agency.
Skilled Nursing Facility
    • Anthem Blue Cross will authorize inpatient services provided in a skilled nursing facility only if all of the following criteria are met:
      • You require daily skilled nursing or rehabilitation, as certified by the attending physician;
      • You were an inpatient in a hospital for at least three consecutive days, and are to be admitted to the skilled nursing facility within 30 days of your discharge from the hospital;
      • You will be treated for the same condition for which you were treated in the hospital; and
      • The care that you will receive is medically necessary and is not custodial, as determined by Anthem Blue Cross.
Durable Medical Equipment
  • Pre-authorization is required for the purchase or rental of durable medical equipment for which the total price costs $1,000 or more.
How to Obtain an Authorization
For Authorized Referrals
You or your physician must call the toll-free telephone number printed on your identification card prior to scheduling an admission to a non-network facility or receiving the services of, a non-network provider.
For Special Services
To obtain authorization, you or your physician must call the Anthem Blue Cross pre-authorization and pre-service review toll-free number at 800-274-7767 prior to receiving services.