Anthem BCBS Upcoming Prior Authorization Requirement Changes for Certain Services

December 2019 ~

Effective February 1, 2020, Anthem Blue Cross Blue Shield (BCBS) will make changes to its prior authorization (PA) requirements for certain services to be covered for Medicare Advantage members.

According to the insurer’s announcement, federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Anthem notes that noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following codes:

  • E0784: ext amb infusion pump insulin
  • K0553: supply allowance for a therapeutic continuous glucose monitor, includes all supplies and accessories, one month supply = one unit of service
  • K0554: receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system

For more information, detailed prior authorization requirements can be accessed using the Provider Self-Service Tool on Anthem’s Availity Portal.

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Source(s): Anthem Blue Cross Blue Shield Provider Bulletin, October 2019;