Anthem & Empire BCBS to Conduct Coding Reviews and Precert Efforts

BCBSAnthem BCBS of Connecticut, Indiana, Ohio, New Hampshire and Empire BCBS of New York are working with OrthoNet, LLC to process precertification requests and conduct post service prepayment coding reviews of professional services for their Medicare Advantage members. This program began on January 1, 2015 and is for professional claims only. Facility claims are excluded.

Effective Jan. 1, 2015, the following services and treatment requests must be reviewed by OrthoNet for precertification. Clinical information should be submitted to OrthoNet at least three business days before the requested procedure to allow a thorough clinical analysis.

  • Physical therapy
  • Occupational therapy
  • Spine and Back Pain Management procedures:
    • Epidurals
    • Facet Blocks
    • PainPumps
    • Neurostimulators
    • Spinal Fusion
    • Spinal Decompression o Vertebro/Kyphoplasty

Also effective January 1, 2015, OrthoNet will conduct post service prepayment coding reviews of the following professional services:

  • Cardiology
  • Neurology
  • Sports Medicine
  • Podiatry
  • Pain Management
  • Psychiatry/physical medicine and rehabilitation
  • ENT
  • Dermatology
  • Urology
  • Percutaneous coronary intervention (PCI)

Precertification for the above services can be obtained by phone at 844-788-4805 or by fax at 844-788-4806.

A complete list of precertification requirements can be found at the Provider Forms section of the Medicare Advantage Public Provider Portals for both Anthem and Empire BCBS.