Quick Reference Card Form

Provider Quick Reference Card https://providers.anthem.com/nv Prior authorization/notification requirements | Important phone numbers | Revenue codes Nevada Medicaid and Nevada Check Up Nevada | Anthem Blue Cross and Blue Shield Healthcare Solutions | Medicaid Managed Care

Easy access to prior authorization/notification requirements and other important information for Anthem Behavioral health/substance use services • Prior authorization is required for coverage of inpatient mental health and substance use disorder services. • Residential substance use disorder detoxand withdrawal management requires prior authorization and is only available for members under age 21. within freestanding hospitals • Residential substance use and withdrawal management requires prior authorization and is only available within an IMD setting for members ages 21 to 64 • Partial hospitalization and intensive outpatient services require prior authorization. • No prior authorization is required for the coverage of traditional outpatient services such as individual, group and family therapies, and medication management unless service limitations are met. • Certain rehabilitation services (such as basic skills training, psychosocial rehabilitation, and day treatment) require prior authorization or notification. Contact 844-396-2330 for information about specific prior authorization requirements. • Psychological and neuropsychological testing require prior authorization. The Request for Authorization — Psychological Testing form is located on our website. • Electroconvulsive therapy (ECT) requires prior authorization. Cardiovascular devices Prior authorization is required for external defibrillators and ventricular assist devices. Chemotherapy • Prior authorization is required for coverage of inpatient chemotherapy services. • No prior authorization is required for coverage of chemotherapy procedures when performed in outpatient settings by a participating facility, provider office, outpatient hospital, or ambulatory surgery center. For information on prior authorization requirements for (and coverage of) chemotherapy drugs, see the Pharmacy section of this QRC. For more information about requirements, benefits, and services, visit our provider website to get the most recent, full version of our provider manual. If you have questions about this quick reference card (QRC), call Provider Services at 844-396-2330. Requirements listed are for network providers. In many cases, out-of-network providers may be required to request prior authorization for services when network providers do not. If services are rendered when prior authorization has been denied or not obtained, claims may be denied. For any claim denials, the dispute and appeal process must be followed, or denials will stand. Learn more about disputes in the Payment Dispute section of this QRC, by visiting our website https://providers.anthem.com/nevada- provider/claims/claims-submissions-and- disputes, or by calling Provider Services at 844-396-2330. Circumcision Prior authorization is not required up to 1 year of age. Dermatology services • No prior authorization is required for network providers for evaluation and management (E/M), testing, and most procedures. • Services considered cosmetic in nature are not covered. • Services related to previous cosmetic procedures are not covered. See the Diagnostic Testing section of this QRC. Diagnostic testing • No prior authorization is required for routine diagnostic testing. • Prior authorization is required for coverage of certain magnetic resonance angiograms, MRIs, computerized axial tomographies, positron emission tomographies, and nuclear cardiac scans, video electroencephalograms, electromyograms, and in-lab sleep studies. Request prior authorizations and give us notifications: • Log in to Availity Essentials. Select Patient Registration, then Authorizations & Referrals. • By phone: 844-396-2330 • By fax: 800-964-3627 • For behavioral health requests, they should be submitted using our preferred digital method at https://Availity.com. If you prefer to paper fax, use the correct forms at https://www.anthem.com/nv/provider. Prior authorization — the act of authorizing specific services or activities before they are rendered or occur Notification — by phone, fax, or electronic communication received from a provider to inform us of the provider’s intent to render covered medical services to a member: • Send us a notification prior to rendering services outlined in this document. • For emergency or urgent services, send us notification within 24 hours or the next business day if a member is admitted. • There is no review against medical necessity criteria; however, we verify member eligibility and provider status (network and non-network). For code-specific requirements for all services, visit https://anthem.com/nv/provider and select Prior Authorization & Claims from the menu. Prior authorization/notification instructions and definitions

Hospital admission • Elective admissions require prior authorization for coverage. • Emergency admissions require notification within five business days. • To be covered, preadmission testing must be performed by an Anthem-preferred lab vendor or network facility outpatient department. See your Provider Referral Directory for a complete listing of participating vendors. • Rest cures, personal comfort, and convenience items, and services and supplies not directly related to the care of the patient (such as telephone chargers, take-home supplies, and similar costs) are not covered. Hysterectomies • Hysterectomies are not covered for the sole purpose of sterilization. • Hysterectomy consent forms are required for all provider types. Sterilization forms are not required for anesthesiology providers only. Forms can be found at https://www.medicaid.nv.gov/providers/forms/forms. Laboratory services (outpatient) All laboratory services furnished by non-network providers require prior authorization except for hospital laboratory services in the event of an emergency medical condition. For offices with limited or no office laboratory facilities, lab tests may be referred to one of the Anthem-preferred lab providers. See your Provider Referral Directory for a complete listing of participating providers. https://providers.anthem.com/nevada- provider/resources/referrals Long-term care Prior authorization and a plan of care are required. Anthem is responsible for the first 180 days of a nursing facility stay. On and after day 181, Medicaid Fee-For-Service covers the stay. Medical supplies No prior authorization is required for coverage of disposable medical supplies. Disposable medical supplies are disposed of after use by a single individual. Durable medical equipment (DME) • No prior authorization is required for coverage of glucometers, dialysis and end-stage renal disease equipment, standard walkers, blood pressure aids, or equipment supplied by network providers. • Prior authorization is required for all rental DME equipment. When rental is available, this is usually required first until the purchase price is met. • Prior authorization is required for coverage of certain prosthetics, orthotics, and DME. For code-specific prior authorization requirements for DME, prosthetics, and orthotics ordered by network providers or network facilities, please refer to our provider website. See Medical Supplies for guidelines relating to disposable medical supplies. • All custom wheelchair requests require an Anthem medical director’s review. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) visit • Members may self-refer for these services. • Use the EPSDT schedule and document visits. • Vaccines received under the Vaccines for Children program cannot be reimbursed. Emergency services No prior authorization or notification is required for emergency care given in the ER. If emergency care results in admission, notification to Anthem is required within five business days. For observation authorization requirements, see the Observation section of this QRC. Ear, nose, and throat services (ENT) or otolaryngology • No prior authorization is required for network providers for E/M, testing, or certain procedures. • Prior authorization is required for many services. Refer to our Prior Authorization Lookup Tool at https://anthem.com/nv/provider. See the Diagnostic Testing section of this QRC. Musculoskeletal services Prior authorization is required for certain arthroscopic procedures, arthrodesis, arthroplasty (including total disc), and vertebroplasty. Neurology • No prior authorization is required for network providers for E/M and testing. • Nerve conduction testing and electromyelogram (EMG) require prior authorization. See the Diagnostic Testing section of this QRC. Observation Observation admissions up to 48 hours do not require prior authorization and are allowed per the Nevada Medicaid Services Manual. Observation beyond 48 hours is not covered. If observation results in inpatient admission, notification to Anthem is required within five business days. Family planning, STD care Members may self-refer to an in-network or out-of-network provider. Gastroenterology services No prior authorization is required for network providers for E/M, testing, or certain procedures. See the Diagnostic Testing section of this QRC. Gynecology • Members may self-refer to network providers. • No prior authorization is required for E/M, testing, and most procedures. • Prior authorization is required for some procedures and services considered cosmetic in nature. See the Diagnostic Testing section of this QRC. Hearing aids Prior authorization is required for digital hearing aids. Hearing screening Network providers do not require notification or prior authorization to cover diagnostic and screening tests, hearing aid evaluations, or counseling.
Home healthcare • Prior authorization is required. • Covered services include skilled nursing, home health aide, physical, occupational, and speech therapy services, and physician-ordered supplies.
• Skilled nursing and home health aides require prior authorization. See the Rehabilitation therapy section of this QRC. • Drugs and DME require separate prior authorization. See the DME and Pharmacy sections of this QRC for more information.

Obstetrical (OB) care • No prior authorization is required for coverage of OB services, including OB visits, certain diagnostic tests and laboratory services when performed by a participating provider. • Notification to Anthem is required at the first prenatal visit. No prior authorization is required for coverage of labor/delivery or for circumcision for male newborns up to and including 1 year of age. • Notification of delivery is required within 24 hours with newborn information (such as the baby’s sex, weight, gestational age, and disposition at birth). • OB and neonatal intensive care unit (NICU) case management programs are available to members. See the Diagnostic Testing section of this QRC. Ophthalmology • No prior authorization is required for E/M, testing, or certain procedures. • Prior authorization is required for repair of eyelid defects. • Services considered cosmetic in nature are not covered. See the Diagnostic Testing section of this QRC. Oral maxillofacial Prior authorization is required. Temporomandibular joint (TMJ) syndrome-related services are not covered. See the Plastic/cosmetic/reconstructive surgery section of this QRC. Otolaryngology (ENT) services See the ENT services or otolaryngology section of this QRC. • Most self-injectable medications and self-administered oral specialty medications, and many office-administered specialty medications are available through CarelonRx Specialty Pharmacy and require prior authorization. To initiate a prior authorization request, call us at 844-396-2330. Effective July 1, 2025, most specialty prescriptions will be transferred to BioPlus, CarelonRx, Inc.’s specialty pharmacy. • Call CarelonRx at 833-262-1726 to schedule delivery once you receive a prior authorization approval notice. For a complete list of drugs available through CarelonRx Specialty, visit the Pharmacy section of our provider website. • To find out if a specific medication requires prior authorization, please refer to our Prior Authorization Lookup Tool found in the Prior Authorization & Claims section of our provider website. • Per NV SB167 (2023), antipsychotic step therapy may be bypassed by applicable practitioners. Refer to the attestation on the relevant prior authorization forms found at https://providers.anthem.com/nv. Personal Care Services • Provides in-home assistance for activities of daily living related to a disability or chronic condition. • Requires a FASP/functional assessment by certified physical or occupational therapist. • Prior authorization is required. • Members can self-refer. Plastic/cosmetic/reconstructive surgery (including oral maxillofacial services) • No prior authorization is required for coverage of E/M codes. • All other services require prior authorization for coverage. Services considered cosmetic in nature are not covered. Services related to previous cosmetic procedures are not covered. Reduction mammoplasty requires an Anthem medical director’s review. prior authorization. • Gender-affirming surgeries require mandatory medical director review. • No prior authorization is required for coverage of oral maxillofacial E/M services. • Prior authorization is required for coverage of trauma to the teeth and oral maxillofacial, medical, and surgical conditions. TMJ-related services are not covered. See the Diagnostic Testing section of this QRC. Podiatry • Podiatry services are covered. Some procedures require prior authorization. • As a value-added benefit exclusive to Anthem members, Anthem allows reimbursement for some podiatry services for our diabetic members over 21 years of age. See the provider manual for specific coverage. See the Diagnostic Testing section of this QRC. Preventative Adult Health Services • Members may self-refer for these services. • Preventative exams are covered once per calendar year when performed by a PCP or in-network gynecologist and include Pap test, examination, routine lab work, and STD screening • Mammograms are covered annually for members aged 40 or older, and every 3 years for members aged 20 to 39. • For family planning services, a member can receive services without authorization from any qualified provider and without regard to network affiliation. Radiation therapy Prior authorization is required for some radiation therapy procedures and brachytherapy. Radiology Anthem has implemented its Physician Radiology Redirection program. The program stipulates that diagnostic procedures for Anthem members will not be reimbursed at the office level (Place of Service 11) and will require that members be directed to one of our in-network freestanding diagnostic locations. Refer to the Physician Radiology Redirection policy for more information at https://providers.anthem.com/docs/gpp/NV_CAID_ PhysicianRadiologyRedirect.pdf. Out-of-area/out-of-network care All out of network services require a prior authorization, except for emergency services, family planning, and certain OB services. Outpatient/ambulatory surgery • Prior authorization requirement is based on the service performed. Visit our provider website for procedure-specific prior authorization requirements. • Prior authorization is required for bariatric surgery (including insertion, removal, and replacement of adjustable gastric restrictive devices). • Prior authorization is required for spinal fusion and artificial intervertebral disc surgery. Pain management/physiatry/ physical medicine and rehabilitation Prior authorization is required for coverage of most procedures related to pain management. Pharmacy • The pharmacy benefit covers medically necessary prescriptions and over-the-counter medications prescribed by a licensed provider. Exceptions and restrictions exist as the benefit is provided under a closed formulary/Preferred Drug List (PDL). Please refer to the PDL for the preferred products within therapeutic categories as well as requirements around generics, prior authorization, step therapy, quantity edits, and the prior authorization process.

Rehabilitation therapy, occupational therapy, physical therapy, and speech therapy (short-term) • No prior authorization is required for evaluation. • Prior authorization is required for coverage of treatment. • Therapy services required to improve a child’s ability to learn or participate in a school setting should be evaluated for school-based therapy. • Other therapy services for rehabilitative care will be covered as medically necessary and as outlined in the Nevada Medicaid Services Manual. Skilled nursing facility Prior authorization is required. Sleep studies Prior authorization is required for in-lab sleep studies. Sterilization • No prior authorization or notification is required for coverage of sterilization procedures, including tubal ligation and vasectomy for members 21 years of age or older. • A Sterilization Consent Form is required for claims submission. Sterilization forms are not required for anesthesiology providers only. Hysterectomy consent forms are required for all provider types. Forms can be found at https://www.medicaid.nv.gov/providers/forms/forms. • Reversal of sterilization is not a covered benefit. Transportation No prior authorization or notification is required for emergency transportation. Emergency air transportation requires post-service authorization, while elective air and ambulance require prior authorization. Urgent care center • Members may self-refer to these facilities. • No notification or prior authorization is required for participating facilities. Revenue (RV) codes To the extent the following services are covered benefits, prior authorization or notification is required for all services billed with the following RV codes: • All inpatient and behavioral health accommodations • 0023 — home health prospective payment system • 0240-0249 — all-inclusive ancillary psychiatric • 0570-0572, 0579 — home health aide • 0632 — pharmacy multiple sources • 0901, 0905-0907, 0913, 0917 — behavioral health treatment services • 0944-0945 — other therapeutic services • 0961 — psychiatric professional fees • 3101-3109 — adult day care and foster care Important contact information Our service partners Blue View Vision (vision services) Members: 877-369-1439 (TTY: 711) Providers: 888-581-3648 Blue View Vision partners with EyeMed Vision Care for provider contracting and network management.
Providers must be contracted with EyeMed to render services. Carelon Medical Benefits Management, Inc. (radiology prior authorization) 833-419-2139 MTM (nonemergent transportation) (for Medicaid members oly) 844-879-7341 Carelon Rx (pharmacy) 844-396-2330 BioPlus, CarelonRx, Inc. (specialty pharmacy) 833-262-1726 Provider Services team 844-396-2330 Our Provider Services team offers prior authorization, case and disease management, automated member eligibility, claims status, health education materials, outreach services, and more. Call Monday through Friday from 8 a.m. to 6 p.m. PT Closed holidays: New Year’s Day, Memorial Day, Juneteenth, July 4th, Labor Day, Thanksgiving, Family Day (Day after Thanksgiving), Christmas Day Anthem provider website — Get help 24/7 https://providers.anthem.com/nevada-provider/home Did you know you can verify member eligibility, look up prior authorization/notification requirements, and so much more on our provider website?
Can’t access the internet? Call Provider Services at 844-396-2330 and simply say your NPI when prompted by the recorded voice. The recording will guide you through our menu of options; just select the information or materials you need when you hear it. Claims Submitting your claims: • Submit using Availity Essentials:

– From the Availity Essentials home page, select Claims & Payments from the top navigation.

– Select Type of Claim from the drop-down menu. • Submit electronically through a clearinghouse or use your practice management software:

– Payer ID: 00265

– For a full list, visit https://Availity.com: https://essentials.availity.com/static/public/onb/ onboarding-ui-apps/payer-list-ui/#/

– Note: If you use a clearinghouse, billing service or vendor, work with them directly to determine payer ID. • Submit paper claims: Anthem Blue Cross and Blue Shield Healthcare Solutions Nevada Claims P.O. Box 61010 Virginia Beach, VA 23466-1010 Timely filing limits: • 180 days from the date of service to submit a clean claim (unless otherwise stated in the Provider Agreement) • Out-of-state and emergency transportation: 365 days from the last date of service • If other health insurance exists: 180 days from the date of the Explanation of Payments (EOP) for in-network/participating providers (365 days from the EOP for out of state providers) • Level One Claim Dispute: 90 days from the date of the EOP • Level Two Claim Dispute: 30 days from the date of the Level One reconsideration decision letter/correspondence Claims submitted outside of the timely filing limits may be denied. For any claim denials, the dispute and appeal process must be followed, or denials will stand. Checking claim status and reviewing claim processing rationale: • Claims Status inquiry:

– Check status directly in Availity Essentials: • From the Availity Essentials home page, select Claims & Payments from the top navigation. • Select Claims Status from the drop-down menu.

– Call Provider Services: 844-396-2330 • Clear Claims Connection:

– Our Clear Claims Connection tool is available to help you review procedure code edits and receive edit rationale. Before disputing a claim, be sure to use this tool to help reduce the number of disputes you must file.

– From the Availity Essentials homepage select Payer Spaces from the top navigation.

– Select the health plan.

– From the Payer Spaces homepage, select the Applications tab.

– Select the Clear Claims Connection tile.

Payment dispute and appeal: • Claims Reconsideration Dispute (Level One):

– To dispute a claim: • From the Availity Essentials homepage, select Claims and Payments from the top navigation. • Select Claims Status from the drop-down menu. • Submit an inquiry and review the Claims Status Detail page:

– If the claim is not eligible for reimbursement or final, there will be an option to dispute the claim. • Select Dispute the Claim to initiate the process. • Navigate to Claims and Payments, then select Appeals. Locate your initiated dispute, upload your documentation, and submit. • Claim Appeal (Level Two):

– A Second Level Claim Payment Appeal must be received within 30 calendar days from the date of the first level decision/resolution letter.

– Option 1: Using Availity Essentials: • From the Availity Essentials homepage, select Claims and Payments from the top menu. • Select Claims Status Inquiry from the drop-down menu. • Submit an inquiry and review the Claims Status Detail page:

– If the claim is not eligible for reimbursement or final, there will be an option to dispute the claim. • Select Dispute the Claim to begin the process.

– Option 2: Mailing a written appeal: • A written Claim Payment Appeal request can be mailed to the following address: Anthem Payment Disputes Payment Dispute Unit P.O. Box 61599 Virginia Beach, VA 23466-1599 • The request must include supporting documentation such as an EOP or other written explanation along with the copy of the claim. If not accompanied by a full explanation the claim may be returned and not accepted. If you have questions on a claim, you may also call Provider Services at 844-396-2330 or use the Chat with Payer or Secure Messaging features in Availity Essentials. Electronic data interchange (EDI) Contact Availity Client Services with any questions at 800-Availity (282-4548). Availity’s EDI submission options: • EDI Clearinghouse for direct submitters (requires practice management or revenue cycle software) or • Use your existing clearinghouse or billing vendor (work with your vendor to ensure connection to the Availity EDI Gateway) For more information on EDI (or to register), visit providers.anthem.com/nv. Medical appeals When a prior authorization is denied, medical appeals may be initiated by a member, a person acting on behalf of a member, a member’s PCP, or a member’s healthcare provider within 60 calendar days from the date of the notice of adverse benefit determination. Medical appeals can be submitted in writing to the following address: Anthem Blue Cross and Blue Shield Healthcare Solutions Medical Appeals P.O. Box 62429 Virginia Beach, VA 23466-2429 Health services Care management services • 844-396-2330 We offer care management services to members who are likely to have extensive healthcare needs. Our clinical care managers work with you to develop tailored care plans based on comprehensive screeners and assessments, including identifying community resources, providing health education, monitoring compliance, assisting with transportation, etc. We offer different stratifications of care management, ranging from short-term care coordination to higher-acuity case management. Condition Care (CNDC) services • 888-830-4300 CNDC services are a form of care management that focuses on specific condition processes and includes educational information, such as local community support agencies and events, in the health plan’s service area. Services are available for members with the following medical conditions: asthma, bipolar disorder, chronic obstructive pulmonary disease, chronic heart failure, coronary artery disease, diabetes, HIV/AIDS, hypertension, major depressive disorder for adults and children/adolescents, schizophrenia, and substance use disorder.
24/7 NurseLine • 844-396-2329 (TTY 711) Members may call our 24/7 NurseLine for nursing advice 7 days a week, 365 days a year. When a member accesses this service, a report will be faxed to your office within 24 hours of receipt of the call. Behavioral Health Crisis Line 844-396-2331 (TTY 711) Members with a behavioral or mental health condition or substance use issue can call our 24/7 Behavioral Health Crisis Line. Member Services • 844-396-2329 (TTY 711) Member-facing service to call for general questions, concerns, help finding providers and scheduling appointments, obtaining value-added benefits (VABs), and requesting care management services.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. NVBCBS-CD-096387-25 Learn more about Anthem programs https://providers.anthem.com/nv