8 / 18
8
Pre-service Review Requirements
Pre-service review establishes in advance the medical
necessity of certain care and services covered under
the Anthem Blue Cross HMO or PPO medical plans. Not
all services which require pre-service review are listed
here. For a complete list of services requiring pre-service
review, contact Anthem Blue Cross at the telephone
number listed on the back of your ID card.
Pre-service
review is required under both the HMO and PPO
medical plans for facility-based care for the treatment
of mental or nervous disorders, severe mental
disorders, and substance abuse.
Anthem Blue Cross PPO
Pre-service review is also required for the following
services under the Anthem Blue Cross PPO:
• Scheduled, non-emergency inpatient hospital stays
and residential treatment center admissions (except
inpatient hospital stays for maternity care of 48
hours or less following a normal delivery or 96 hours
or less following a cesarean section and mastectomy
and lymph node dissection)
• Transplant services
• Visits for physical therapy, physical medicine,
occupational therapy and chiropractic care beyond
24 combined visits per calendar year
• Home health care; home infusion therapy
• Admission to a skilled nursing facility
• Surgical treatment for morbid obesity performed
at a Centers of Expertise facility
• Select imaging procedures including MRI, CAT scan,
PET scan, MRS scan, MRA scan and Nuclear Cardiac
Imaging
• Certain types of Durable Medical Equipment
including ultra lightweight wheelchairs, motorized/
power wheelchairs, power operated vehicles and
related accessories
HMO and PPO providers will initiate a pre-service
review on your behalf. Non-PPO providers may initiate
the review for you, or you may call Anthem Blue Cross
directly at the toll-free telephone number for pre-
service review printed on your ID card.
It is your responsibility to confirm that the review
has been performed. Failure to obtain pre-service
authorization for an inpatient hospital or residential
treatment center admission or the facility-based care
for the treatment of mental or nervous disorders
and substance abuse will be subject to a $350 non-
certification penalty.