News & Announcements

Specialty Pharmacy Prior Authorization Updates

Effective for dates of service on and after January 1, 2021, some specialty pharmacy codes from current or new clinical criteria documents will be included in our precertification review process.


AIM Clinical Appropriateness Guidelines for Radiation Oncology

The following updates will apply to the AIM Specialty Health Clinical Appropriateness Guidelines for Radiation Oncology for claims with dates of service on and after March 14, 2021. AIM Specialty Health is an independent company providing utilization review service on behalf of BlueChoice HealthPlan


Rituxan Biosimilars Medical Step Therapy Notice

January 1, 2021, the following specialty pharmacy drugs and corresponding codes from current Clinical Criteria will be included in our medical step therapy precertification review process.


Independent laboratory provider — Place of service 81


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Racial Trauma Forum Invitation


Notification regarding inhaled nitric oxide

The purpose of this notification is to inform participating hospitals that the use of inhaled nitric oxide (iNO) during an inpatient stay will be reviewed for medical necessity using our Clinical Utilization Management (UM) Guideline for Inhaled Nitric Oxide, CG-MED-69. iNO is a covered service for eligible members when the use of iNO meets medical necessity criteria.


Update: Notice of changes to the AIM Musculoskeletal Program

Effective November 1, 2020, according to the AIM Level of Care guideline, it is generally appropriate to perform joint codes (CPT® codes 27130, 29871, 29892) and four spine codes (CPT codes 22633, 22634, 63265 and 63267) in a hospital outpatient setting.


Updates to AIM Sleep Disorder Management Clinical Appropriateness Guideline

Effective for dates of service on and after August 16, 2020, the following updates will apply to the AIM Specialty Health®* (AIM) Sleep Disorder Management Clinical Appropriateness Guideline.


Availity Provider FAQ and Availity Notification

Starting March 9, 2020, Anthem will launch the use of Availity’s Medical Attachment functionality for electronic communications. This new functionality allows providers to upload medical records and itemized bill information electronically instead of through traditional paper communications. This functionality can improve communications for medical record requests and receipt and will not impact the audit program.


Clinical Criteria Web Posting September 2019

On September 19, 2019, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised or reviewed to support clinical coding edits.


Prenatal service third-party liability change

The Bipartisan Budget Act of 2018 makes changes to the coordination of benefits process for prenatal services, which formerly received special treatment under Medicaid third-party liability requirements. This law directs Medicaid to apply the standard coordination of benefits rule when processing claims for prenatal services. In accordance, Anthem Blue Cross and Blue Shield (Anthem) will implement these changes effective November 1, 2019.


Personal Care Worker Training

Anthem Medicaid presented the health plan’s precertification and claims filing requirements for Personal Care Workers at the WPSA December 2018 Conference. The PowerPoint can be accessed at the link below.



Personal care agencies, click the link below for instructions on how to sign up for EFT.


Change in AIM Effective Date to April 1

The implementation date has changed to April 1 for Anthem Blue Cross and Blue Shield (Anthem) to transition its Outpatient Rehabilitation Utilization Management (UM) program to AIM Specialty Health® (AIM), a specialty health benefits company. The Outpatient Rehabilitation UM program includes physical, occupational and speech therapy services.



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