Payment for Plan benefits is based on, among other things, medical necessity of the service or procedure. Before you receive medical care, we want to give you and your provider the opportunity to verify coverage of a service. This is called a pre-authorization process. In order to make the pre-authorization process as easy as possible, we are shifting the majority of medical pre-authorizations to Anthem. Our partners at Anthem have a comprehensive list of services that they review. For your convenience, here is the most current list of services that are part of Anthem’s pre-authorization process:
Please have your provider call Anthem to follow the necessary pre-authorization procedures before you receive care. If you still have questions about what medical procedures are covered or don’t see the service you are considering on Anthem’s list, we are still here to help. The Plan will not deny benefits on the basis that a pre-authorization was not obtained. While pre-authorizations are not required, they are recommended. Some services may not be a Plan benefit or meet the requirement of medical necessity.