Certain procedures have pre-authorization requirements, as described below and throughout this SPD. While a Claim will not be denied, nor payment reduced, simply because it was not pre-authorized, it is very important that you and your Provider seek pre-authorization for these services. The pre-authorization process can assist you, your Provider and the Plan in detecting any issues before the service is performed, so that you can avoid issues later on. Payment for Plan benefits is based upon, among other considerations, whether the treatment or procedure is Medically Necessary or Experimental or Investigative, as defined in the Health Plan Glossary, and obtaining pre-authorization can address these issues before services are rendered.
- The following are examples of services for which you must obtain pre-authorization in advance, due to the nature of the services:
- Bariatric surgery
- Eyelid surgery
- Gender reassignment / confirmation surgery
- Genetic testing Outpatient monitored anesthesia care
- Nasal surgery
- Neuropsychological testing
- Reconstructive surgery and other breast surgeries (other than as required under the Women’s Health and Cancer Rights Act
- Sleep study Spinal surgery
- TMJ therapy
- Any potentially Investigative or Experimental testing or treatment
Even if pre-authorization is not required by the Plan, you may request certain pre-authorizations in order to have a better idea as to whether and to what extent a service will be covered.
Anthem assists the Plan in performing certain pre-authorizations. Anthem maintains an extensive list of items for which it performs pre-authorizations. That list can be found at www.anthem.com/ca/provider/priorauthorization and is available upon request from the Plan Office. Participants may submit requests for pre-authorization of services not on the Anthem list directly to the Plan.
Also, please refer to the SPD’s prescription drug benefits for information regarding pre-authorization for medications, which is not handled by Anthem and may be required in order to obtain coverage. You should note that, if your Provider participates with Anthem, the contract between the Provider and Anthem may require the Provider to obtain pre-authorization from Anthem for services not listed in this SPD. Those requirements are between the Provider and Anthem and are separate from the Plan’s requirements and can affect the Provider’s right to payment under the Anthem contract.
If you have any questions regarding pre-authorization, please contact the Plan Office.