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Mental Health/Substance Abuse (MHSA):
Pre-Certification Required
Acute Inpatient Admissions
Transcranial Magnetic Stimulation (TMS)
Intensive Outpatient Therapy (IOP)
Partial Hospitalization (PHP)
Residential Care
Behavioral Health in-home Programs
The following services do not require precertification, but are recommended for pre-determination
of Medical Necessity due to the existence of post service claim review criteria and/or the potential
cost of services to the Member if denied by for lack of Medical Necessity: Procedures, equipment,
and/or specialty infusion drugs which have Medically Necessary criteria determined by the Claims
Administrator’s Medical Policy or Clinical Guidelines.
Who is Responsible for Precertification?
Typically, Network Providers know which services need Precertification and will get any Precertification
when needed. Your Primary Care Physician and other Network Providers have been given detailed
information about these procedures and are responsible for meeting these requirements. Generally, the
ordering Provider, Facility or attending Doctor (“requesting Provider”) will get in touch with the Claims
Administrator to ask for a Precertification. However, You may request a Precertification or You may choose
an authorized representative to act on Your behalf for a specific request. The authorized representative
can be anyone who is 18 years of age or older. The table below outlines who is responsible for
Precertification and under what circumstances.
Provider Network Responsibility to Comments
Status Get Precertification
Network, including Provider The Provider must get Precertification when
BlueCard Providers in required
the service areas of
Anthem Blue Cross and
Blue Shield (CO, CT, IN,
KY, ME, MO, NH, NV,
OH, VA, WI); Anthem
Blue Cross (CA); Empire
Blue Cross Blue Shield;
Anthem Blue Cross Blue
Shield (GA); and any
future affiliated Blue
Cross and/or Blue Shield
plans resulting from a
merger or acquisition by
the Claims
Administrator’s parent
company.
Out-of- Network/ Member Member must get Precertification when
Non-Participating required. (Call Member Services.)
Member may be financially responsible for
charges/costs related to the service and/or
setting in whole or in part if the service
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Pre-Certification Required
Acute Inpatient Admissions
Transcranial Magnetic Stimulation (TMS)
Intensive Outpatient Therapy (IOP)
Partial Hospitalization (PHP)
Residential Care
Behavioral Health in-home Programs
The following services do not require precertification, but are recommended for pre-determination
of Medical Necessity due to the existence of post service claim review criteria and/or the potential
cost of services to the Member if denied by for lack of Medical Necessity: Procedures, equipment,
and/or specialty infusion drugs which have Medically Necessary criteria determined by the Claims
Administrator’s Medical Policy or Clinical Guidelines.
Who is Responsible for Precertification?
Typically, Network Providers know which services need Precertification and will get any Precertification
when needed. Your Primary Care Physician and other Network Providers have been given detailed
information about these procedures and are responsible for meeting these requirements. Generally, the
ordering Provider, Facility or attending Doctor (“requesting Provider”) will get in touch with the Claims
Administrator to ask for a Precertification. However, You may request a Precertification or You may choose
an authorized representative to act on Your behalf for a specific request. The authorized representative
can be anyone who is 18 years of age or older. The table below outlines who is responsible for
Precertification and under what circumstances.
Provider Network Responsibility to Comments
Status Get Precertification
Network, including Provider The Provider must get Precertification when
BlueCard Providers in required
the service areas of
Anthem Blue Cross and
Blue Shield (CO, CT, IN,
KY, ME, MO, NH, NV,
OH, VA, WI); Anthem
Blue Cross (CA); Empire
Blue Cross Blue Shield;
Anthem Blue Cross Blue
Shield (GA); and any
future affiliated Blue
Cross and/or Blue Shield
plans resulting from a
merger or acquisition by
the Claims
Administrator’s parent
company.
Out-of- Network/ Member Member must get Precertification when
Non-Participating required. (Call Member Services.)
Member may be financially responsible for
charges/costs related to the service and/or
setting in whole or in part if the service
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