Tag: #Medi-Cal

Posted in Insurance, Training, Updates

Anthem Medi-Cal: Radiotherapies and radioimmunotherapies will require prior authorization 04/01/2021

Posted on by KR2Medical Billing

PA requirements will be added to the following codes:

  • A9543 Injection, Yttrium Y-90 ibritumomab tiuxetan (Zevalin)
  • A9590 Injection, Iodine I-131, iobenguane, 1 mCi (Azedra)
  • A9513 Injection, Lutetium Lu 177, dotatate, therapeutic, 1 millicurie (Lutathera)
  • A9606 Injection, Radium ra-223 dichloride, therapeutic, per microcurie (Xofigo)

Effective 04/01/2021 the above codes will require an auth.

Providers have 2 ways to order a PA:

Federal and state law, as well as state contract language, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.

Posted in Insurance, Training, Updates

Anthem Medi-Cal: Hospital Reimbursement Policy Update- 05/01/21

Posted on by KR2Medical Billing

Currently Anthem Medi-Cal reimburses for services for a covered member prior to admission to an inpatient hospital (referred to as the payment window) unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

However, Emergency and observation services are included in the inpatient reimbursement and, therefore, are not separately reimbursable expenses when performed within 24 hours prior to and including the day of the member’s admission.

Effective 05/01/21- Anthem Medi-Cal the following changes will take effect:

  1. For admitting hospitals: preadmission services are included in the inpatient reimbursement for the three days prior to and including the day of the member’s admission. Therefore, they are not separately reimbursable expenses.
  2. Anthem will not consider the following services to be included in the payment window prior to an inpatient stay for preadmission services:
  • Ambulance services
  • Maintenance renal dialysis services
  • Services provided by:
    • Skilled nursing facilities
    • Home health agencies
    • Hospices
  • Unrelated non-diagnostic services

If you have more information please visit:  https://mediproviders.anthem.com/ca. and review Preadmission Services for Inpatient Stays reimbursement policy