Authorization Program
The Authorization Program provides prior authorization for certain "special services." When your physician is a network provider, it is your physician's responsibility to obtain authorization before you receive any service subject to the Authorization Program. When your physician is a non-network provider, it is your responsibility to obtain authorization before you receive any service subject to the authorization process. 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 "Effect on Benefits" under "Utilization Review Program."
Services Requiring Authorization
Pre-authorization is required to obtain benefits for:
* A $300 penalty is assessed if pre-authorization is not obtained.
Effect on Benefits
  • A $300 penalty is assessed if pre-authorization is not obtained for the following special services: 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
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 at a Center of Medical Excellence (CME) or a facility approved by Anthem Blue Cross for kidney and cornea transplants. 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 must be 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
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.