Why Anthem BCBS Denies Home Health Services
Patient is not homebound
Skilled need not documented
Services exceed reasonable frequency
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
Building Your Medical Necessity Argument
Document homebound status with specific functional limitations
Define the skilled need (wound care, medication management, PT/OT)
Note why outpatient services are not feasible
Reference recent hospitalization or change in condition
P2P Call Tips for Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
Guidelines to Reference
- CMS Home Health Coverage Requirements
- Medicare Benefit Policy Manual Ch. 7
Relevant CPT Codes
Specialty: Internal Medicine / Family Medicine
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