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  • Specialty Pharmacy Program Exception Form - Anthem

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TION 1: PATIENT INFORMATION Last name First name Date of birth ID no. Contact phone no. Address Date of diagnosis City Primary diagnosis First name M.I. Address Phone no. State Zip code ICD-10 Code(s) SECTION 2: PHYSICIAN INFORMATION Last name Tax ID no. M.I. Current weight DEA or NPI no. City Fax no. Office contact name SECTION 3: MEDICATION OR PRESCRIPTION INFORMATION Drug name State ZIP code Physician specialty Strength / Dose Direction for use (SIG) Date medicat.

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Modifier 25 is used when a minor procedure (one with a 0- or 10-day global period) and a significant and separately identifiable evaluation and management (E/M) service are performed during the same session or day.

What do I include with my appeal? If your appeal is about a Part D drug: Your completed Redetermination Request Form. Your name, address and member ID number. Your reasons for appealing. Any information or evidence (documents, medical records) to support your appeal.

You or your provider can request an expedited appeal. Call Member Services toll-free at 844-912-0938 (TTY 711), Monday through Friday from 8 a.m. to 7 p.m. Eastern time. When we receive your call, we will call you within 72 hours to tell you our decision.

Code 99354 or 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service. Either code should be used only once per date, even if the time spent by the physician is not continuous on that date.

Modifier 25 enables you to bill for two separate procedures conducted during the same exam. To ensure you are getting fully reimbursed, however, you must understand the correct way to use this modifier, including the codes it can and cannot be used with.

Claim dispute From the Availity home page, select Claims & Payments from the top navigation. Select Claim Status Inquiry from the drop-down menu. Submit an inquiry and review the Claims Status Detail page. If the claim is denied or final, there will be an option to dispute the claim.

Anthem will allow separate reimbursement for E&Ms performed on the same day of a major surgery (90-day global period) or minor surgery (0-day or 10-day global period) when billed with a modifier 25.

Modifier 25 may be used in the rare circumstance of an E/M service the day before a major operation and represents a significant, separately identifiable service; it likely would be associated with a different diagnosis (for example, evaluation of a cough that might affect the operation).

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232