Anthem BCBS to Require Preauthorization for Outpatient Therapy

June 25, 2019
Rick Gawenda

Effective July 1, 2019, Anthem Blue Cross patients in several states will require preauthorization to receive outpatient physical, occupational and speech therapy services. This will be true not only for new patients beginning therapy on or after July 1, 2019, but also for current Anthem patients who are being seen now and will continue to be seen for therapy on or after July 1, 2019.

The states where prior authorization will be required effective for dates of service on and after July 1, 2019 are:

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  1. We just switched from Orthonet to AIM Spec Health. Had to do my first auth today, no notes requested, only want one icd10 code, complexity of Evaluation billed, and seven yes/no questions for things like BMI > 40, COPD, cognitive impaired, neurological conditions, etc. From that they determine the visits that are warranted. THR patient one month from surgery, five visits. I was told they never require clinicals, so basically never read any of the findings or clinical reasoning of the therapist, just want a score from a functional tool. What fun this will be. Orthonet was pretty bad and this seems right in line with that.

  2. Trying to get on today to do precert for visits for tomorrow and the site keeps crashing with error codes… good luck getting anyone on the phone to assist you as well. We usually treat on the first visit after doing the evaluation guess we will have to tell the patients that due to their insurance requiring PA on all treatment after the Eval for us to be paid we will not be able to treat.

  3. We have started to try and get the preauths as of yesterday. We are having a lot of issues. Have you heard of any issues?

  4. Can you please clarify if this applies to the patient’s plan being based out of that state or not. For example a patient with Anthem Blue Cross of California who is currently having treatment in Arizona. Would the Arizona provider need to contact AIM?

    1. I would suggest you contact the patient’s insurance carrier if you have questions whether or not preauthorization is required. My opinion is preauthorization would be required if the patient has Anthem in one of the states listed in this article.

  5. Which states require pre-cert ? Also, is this also through AIM. I have been having a terrible time with them with obtaining authorization.

  6. We are based in Alabama and see a handful of patients with CA and GA Anthem plans. I contacted a GA plan this morning to inquire about new the pre-authorization requirements and was told the representatives were informed the requirement was plan specific and we would need to call about each patient. After calling on 5 patients for both GA and CA, none have required pre-authorization. We are getting reference numbers and continuing to call just in case but I’m curious about the discrepancy in information.

  7. Do we know if this will also apply to Medicare PPO BCBS patients who are being seen out of network and submitting the claims themselves?

    1. If they have OON benefits, this would then apply and the OON would submit the request for therapy services.