Maine Precertification/Prior Authorization List

Maine | Anthem Blue Cross and Blue Shield | Commercial

The following guidelines apply to Anthem products issued and delivered by Anthem in Maine. For information on precertification requirements for those members of National Accounts, call the number on the member’s card. To verify member eligibility, benefits, and account information, call the telephone number listed on the back of the member’s ID card.

Precertification/prior authorization is the determination by Anthem that selected inpatient and outpatient medical services (including surgeries, major diagnostic procedures and referrals) are medically necessary. For the member to receive maximum benefits, Anthem must authorize the services for which precertification/prior authorization is required prior to being rendered. Precertification/prior authorization can help avoid unnecessary charges or penalties by helping to ensure that the member’s care is medically necessary and administered at an appropriate network facility and by a network care provider.

Precertification/prior authorization includes:

• A review of both the service and the setting.
• Care will be covered according to the member’s benefits for the number of days authorized unless our concurrent review determines that additional days qualify for coverage.
• Certain services may require the member to use a care provider designated by Anthem’s Utilization Management staff.
• A copy of the approval will be provided to the member and the physician or provider of service.
• For benefits to be paid, the member must be eligible for benefits and the service must be a covered benefit under the contract at the time the services are rendered and the member must not have exceeded any benefit limitations under their plan.

Responsibility for precertification/prior authorization For HMO type health plans — under our HMO plans and products:

• It is the participating physician’s or care provider’s responsibility to contact Anthem’s Utilization Management Department at 800-392-1016, or such other number indicated below for specific services, to obtain prior authorization.

Carelon Behavioral Health is an independent company providing utilization management services on behalf of the health plan. 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 is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MEBCBS-CM-094558-25 | October 2025

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• The request must come from the care provider or facility rendering the service, not the referring physician, except where described below for specific services.
• If prior authorization is not obtained, the claim payment may be reduced or denied by the Plan and the member must be held harmless.

For PPO-type health plans — under our PPO plans and products:

• Services provided by a network care provider: The care provider is responsible for prior authorization.
• Services provided by a BlueCard® or nonparticipating care provider: The member is responsible for prior authorization. The member is financially responsible for services and/or settings that are not covered under the certificate based on an adverse determination of medical necessity or experimental or investigational services.
• Contact Anthem’s Utilization Management Department to obtain precertification at 800-392-1016, or such other number indicated below for specific services.

UM Decisions — appropriateness of care and services As part of our goal to improve the health of the members we serve, we are committed to promoting appropriate utilization of medical services. Please note the following:

• People who make utilization management decisions do not receive compensation or incentives to deny care. This also applies to people who supervise them, including management, medical directors, utilization management managers and licensed staff.
• Utilization management decisions are based only on appropriateness of care and services and existence of coverage. The plan does not specifically reward for denial of services, or offer incentives to encourage denial of services.
• Care providers may contact Carelon Medical Benefits Management, Inc. for prior authorization/preservice clinical review medical necessity reviews of the services listed below through the following options:
  • Access Carelon Medical Benefits Management’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access Carelon Medical Benefits Management via the Availity Web Portal at https://Availity.com.
  • Call the Carelon Medical Benefits Management Contact Center toll-free number: 866-714-1107, Monday to Friday, 8 a.m. to 5 p.m.
• For benefits to be paid, the member must be eligible on the date of service, and the service must be a covered benefit under the policy.

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