Anthem Blue Cross and Blue Shield GA Standard Preapproval CODE List 4/1/2019
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- Zoe Malone
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1 Anthem Blue Cross and Blue Shield GA Standard Preapproval CODE List 4/1/2019 Eligibility and benefits: Eligibility and benefits can be verified by accessing the Anthem Blue Cross and Blue Shield web site or by calling the number on the back of th preapproval is based on member s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subjec implementation dates. The provider is responsible for verification of member eligibility and covered benefits. Except in the case of an emergen rendering the designated services listed below will result in denial of reimbursement. This document includes 4 sections: AIM Specialty Health, AIM MSK, AIM Other Reviews and GA Standard Preapproval Codes DRG, Medical Policy and Clinical Guideline. Deletions could be reviewed post-service. AIM Specialty Health AIM Specialty Health, a separate company, is a nationally recognized leader delivering specialty benefits management on behalf of GA for certain health pl needed for a GA member by clicking the Medical Policy, Clinical UM Guidelines, and Preapproval Requirements link on our provider website, or by calling the back of the member s ID card. To submit your request for any of the services below, contact AIM online via AIM s ProviderPortalsm at From the drop-down menu, select GA. You may also call AIM toll-free at p.m. ET. AIM provides benefits management for the programs listed below: > Imaging Level of Care > Genetic Testing > Diagnostic Imaging Management > Cardiovascular Services > Radiation Therapy Services > Outpatient Sleep Testing and Therapy Services > Specialty Pharmacy Drugs > Cancer Care Quality Program > Musculoskeletal (MSK) Program (Implementation ) > Upper Gastrointestinal Endoscopy (implementation ) For more details on these programs, please visit the AIM Specialty Health site at linked to sites created and/or maintained by another, separate entity ( External Site ). Upon linking you are subject to the terms of use, privacy, copyright a We provide these links solely for your information and convenience. We encourage you to review the privacy practices of the External Sites. AIM Musculoskeletal (MSK) Program: Delay in launch for Fully Insured Implementation The December 2017 edition of the Network Update announced that AIM Specialty Health (AIM), a separate company, perform prior authorization reviews of certain surgeries of the spine and joints, as well as interventional pain treatment determine medical necessity for fully insured Anthem Blue Cross and Blue Shield members. Please be aware that this program has been delayed and the implementation date is yet to be deter The new musculoskeletal program includes review of the level of care/setting, pre-operative days, and expect for medical necessity using AIM clinical guidelines which have been adopted by Anthem Blue Cross and All codes and clinical guidelines included in the musculoskeletal program can be found on the AIM MS AIM Musculoskeletal Program (MSK) Reviews For groups NOT using AIM MSK Anthem policies and guidelines below will be archived on 1/1 For groups using AIM MSK Anthem policies and guidelines below will be archived on 1/1/2019 as noted but th reviewed by BCBSGA using AIM guidelines until AIM starts to perform the reviews on a date yet to SURG Percutaneous Neurolysis for Chronic Neck and Back Pain Delete
2 SURG SURG Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty Percutaneous and Endoscopic Spinal Surgery MSK Program MSK Program MSK Program MSK Program MSK Program MSK Program MSK Program MSK Program Delete 0274T Delete 0275T Delete S2348 Delete SURG SURG Lysis of Epidural Adhesions Implanted Devices for Spinal Stenosis For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program 0202T Delete C1821 Delete SURG Axial Lumbar Interbody Fusion For Fully Insured - reviews moving to AIM MSK Program 0195T Delete 0196T Delete SURG SURGERY SURGERY SURGERY Sacroiliac Joint Fusion Hip Replacement Shoulder Replacement Spinal Surgery 0309T Delete MSK Program Delete For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program
3 For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program Delete Delete Delete For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program Delete Delete CG-SURG-32 CG-SURG S2350 S2351 Pain Management: Cervical, Thoracic and Lumbar Facet Injections T 0214T 0215T 0216T 0217T 0218T Lumbar Fusion and Lumbar Total Disc Arthroplasty (TDA) For Fully Insured - reviews moving to AIM MSK Program For Fully Insured - reviews moving to AIM MSK Program Delete Delete Delete
4 CG-SURG T 0165T Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
5 CG-SURG-39 CG-SURG-42 CG-SURG Pain Management: Epidural Steroid Injections Cervical Fusion Knee Arthroscopy T 0229T 0230T 0231T MSK - implementation date yet to MSK - implementation date yet to MSK - implementation date yet to MSK - implementation date yet to
6 CG-SURG-45 CG-SURG-47 Bone Graft Substitutes G Surgical Interventions for Scoliosis and Spinal Deformity
7 CG-SURG-53 CG-SURG-54 CG-SURG-60 CG-SURG-65 CG-SURG-66 Elective Total Hip Arthroplasty Elective Total Knee Arthroplasty Cervical Total Disc Arthroplasty T 0098T 0375T Recombinant Human Bone Morphogenetic Protein Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) MSK Program MSK Program
8 CG-SURG-67 CG-SURG-68 CG-SURG C1822 L8680 L8682 L8683 L8685 L8686 L8687 L8688 Treatment of Osteochondral Defects of the Knee and Ankle J7330 S2112 Surgical Treatment of Femoroacetabular Impingement Syndrome Meniscal Allograft Transplantation of the Knee AIM Other Reviews MSK Program MSK Program MSK Program MSK Program MSK Program MSK Program MSK Program MSK Program MSK Program MSK Program CG-DRUG-77 Radium RA 223 Dichloride (Xofigo ) Moved to AIM A9606 Moved to AIM CG-MED-58 Coronary Artery Imaging: Contrast-Enhanced CT Angiography, Fractional Flow Reserve derived from CT, Coronary MRA, and Moving to AIM Cardiac MRI Moving to AIM Moving to AIM Moving to AIM Moving to AIM
9 75563 Moving to AIM Moving to AIM Moving to AIM 0501T Moving to AIM 0502T Moving to AIM 0503T Moving to AIM 0504T Moving to AIM CG-MED-59 Upper Gastrointestinal Endoscopy Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM Reviewed by AIM GA Standard Preapproval Code List DRG / Medical Policy / Clinical Guideline Name Code Change Number DRG 219, 220 Cardiac Valve Replacement or Repair Aortic Aneurysm, Thoracic, Repair with Graft
10 DRG 329, 330 ANC ANC Aortic Coarctation, Excision or Repair Cardiac Valve: Ross Procedure Bowel Surgery: Colectomy, Partial, with or without Ostomy Bowel Surgery: Abdominoperineal Resection or Total Colectomy with Proctectomy Bowel Surgery: Colectomy, Partial, with or without Ostomy, by Laparoscopy Bowel Surgery: Small Intestine Resection Intussusception Reduction, Surgical Cosmetic and Reconstructive Services: Skin Related J3490 Cosmetic and Reconstructive Services of the Head and Neck
11 ANC BEH DME Cosmetic and Reconstructive Services of the Trunk and Groin Transcranial Magnetic Stimulation for Depression Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES) E0745
12 E0764 E0770 DME Transtympanic Micropressure for the Treatment of Ménière s Disease E2120 DME Standing Frames E0638 E0641 E0642 E2301 DME Static Progressive Stretch (SPS) and Patient- Actuated Serial Stretch (PASS) Devices E1801 E1806 E1811 E1816 E1818 E1821 E1831 E1841 E1399 NOTE: For drugs NOT listed below, please check the AIM website at aimspecialtyhealth.com DRUG Chelation Therapy J0470 J0600 J0895 J3520 M0300 S9355 DRUG Testopel (testosterone subcutaneous Moving to Ingenio ING-CC implant) Moving to Ingenio ING-CC-0008 J3490 Moving to Ingenio ING-CC-0008 S0189 Moving to Ingenio ING-CC-0008 MED Selected Sleep Testing Services S8040 MED Prolotherapy for Joint and Ligamentous Conditions M0076 MED Wearable Cardioverter Defibrillators K0606 MED MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications C9734 C T 0072T 0398T MED Antineoplaston Therapy J3490 J8499 J8999 J9999 MED Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility MED Disorders Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management C2624 MED Near-Infrared Spectroscopy Brain Screening for Hematoma Detection MED Biofeedback and Neurofeedback Add Add Add Add E0746 Add OR-PR Microprocessor Controlled Lower Limb Prosthesis L5856 L5857 L5858 L5859 OR-PR Powered Robotic Lower Body Exoskeleton Devices L2999 RAD Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
13 T SURG Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement T 0076T SURG Partial Left Ventriculectomy SURG Vagus Nerve Stimulation E1399 L8680 L8685 L8686 SURG Lung Volume Reduction Surgery SURG Breast Procedures including Reconstructive Surgery, Implants and Other Breast Procedures SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG OTHER OTHER SURG SURG SURG C1789 SURG L8600 SURG S2066 SURG S2067 SURG S2068 SURG Bariatric Surgery and Other Treatments for Clinically Severe Obesity CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83
14 T 0313T 0314T 0315T 0316T 0317T SURG Deep Brain Stimulation C1767 C1820 C1822 L8680 L8682 L8683 L8685 L8686 L8687 L8688 SURG Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Conditions C9748 SURG Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention SURG Cardioverter-Defibrillators CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83 CG-SURG-83
15 C1721 C1722 C1777 C1882 C1895 C1896 SURG Treatment of Varicose Veins (Lower Extremities) S T SURG Electrothermal Shrinkage of Joint Capsules, S2300 Ligaments, and Tendons SURG Extracorporeal Shock Wave Therapy for Orthopedic Conditions T 0102T SURG Panniculectomy and Abdominoplasty Mandibular/Maxillary (Orthognathic) Surgery Add
16 SURG Hip Resurfacing D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7995 D S2118 SURG Presbyopia and Astigmatism-Correcting Intraocular Lenses V2788 SURG Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome SURG Photocoagulation of Macular Drusen SURG Epiduroscopy SURG Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA) Content transferring to CG-SURG-85 Content transferring to CG-SURG-85 CG-SURG-87 CG-SURG-87
17 C9749 SURG Implantable Middle Ear Hearing Aids S2230 SURG Mastectomy for Gynecomastia SURG Viscocanalostomy and Canaloplasty SURG Surgical and Ablative Treatments for Chronic Headaches SURG Cryoablation for Plantar Fasciitis and Plantar Fibroma SURG Suprachoroidal Injection of a Pharmacologic Agent 0465T SURG Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir) 0191T 0253T 0376T 0449T 0450T 0474T SURG Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis T S T 0511T SURG Bicompartmental Knee Arthroplasty SURG Ablative Techniques as a Treatment for Barrett's Esophagus SURG Occipital nerve stimulation L8679 L8680 L8685 L8686 SURG Venous Angioplasty with or without Stent Placement or Venous Stenting Alone SURG Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects SURG Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring CG-SURG-87 CG-SURG-87 CG-SURG-87 CG-SURG-87 CG-SURG-87 CG-SURG-87 CG-SURG-87 CG-SURG-87 Add CG-SURG-87 CG-SURG-88 Add Add
18 T 0467T 0468T C9727 S2080 SURG Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography 0351T 0352T 0353T 0354T SURGERY Gallbladder Removal SURGERY Hysterectomy CG-ANC-06 Ambulance Services: Ground; Non-Emergent A0380 A0390 A0425 A0426 A0428 A0432 A0434 CG-ANC-07 Inpatient Interfacility Transfers See Guideline Add
19 CG-BEH-02 Applied Behavioral Analysis for Autism Spectrum Disorder T 0373T H0020 H0031 H0032 H0046 H2012 H2014 H2019 CG-BEH-14 Intensive In-home Behavioral Health Services H0004 H0006 H0023 H0036 H2015 H2019 H2020 CG-DME-06 Pneumatic Pressure Devices E0652 E1399 CG-DME-07 Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) E1902 E2351 E2500 E2502 E2504 E2506 E2508 E2510 CG-DME-31 Wheeled Mobility Devices: Wheelchairs Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) E1002 E1006 E1007 E1009 E1010 E1012 E1230 E1239 E2300 K0010 K0011 K0012 K0013 K0014 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826
20 CG-DME-33 CG-DME-40 CG-DME-42 CG-DME-43 CG-DME-45 CG-DME-46 Wheeled Mobility Devices: Manual Wheelchairs Ultra Lightweight Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton Non-implantable Insulin Infusion and Blood Glucose Monitoring Devices Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV) Ultrasound Bone Growth Stimulation Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Lower Limbs K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 K0898 K0899 K Moving to AIM E0747 E0748 Moving to AIM E0749 Moving to AIM E0784 S1034 A9274 E0784 A7025 E E0760 A4600 E0676 E0650 DME DME Add Add Add
21 E0651 Add E0652 Add E0660 Add E0666 Add E0667 Add E0669 Add E0670 Add E0671 Add E0673 Add CG-LAB-03 Tropism Testing for HIV Management CG-MED-37 Intensive Programs for Pediatric Feeding Disorders See Guidelines CG-MED-46 Electroencephalography and Video Electroencephalographic Monitoring Add CG-MED-63 Hyperhidrosis CG-MED-65 Manipulation Under Anesthesia CG-MED-66 Cryopreservation of Oocytes or Ovarian Tissue T 0357T CG-MED-70 Wireless Capsule Endoscopy for Esophageal and Small Bowel Imaging and the Patency Capsule T CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical) MED G0277 MED CG-MED-74 Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry MED MED MED C1764 MED E0616 MED CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices (previously CG-DME-28) L6611 L6677 L6880 L6881 L6882 L6925 L6935 L6945 L6955 L6965 L6975 L7007 L7008 L7009 L7045
22 L7180 L7181 L7190 L7191 CG-REHAB-08 Private Duty Nursing in the Home Setting S9123 S9124 T1000 T1002 T1003 T1030 T1031 CG-SURG-03 Blepharoplasty, Blepharoptosis Repair and Brow Lift CG-SURG-05 Maze Procedure CG-SURG-08 Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury L8680 L8682 L8684 CG-SURG-12 Penile Prosthesis Implantation CG-SURG-18 Septoplasty CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) S2342 CG-SURG-27 Gender Reassignment Surgery
23 CG-SURG-28 Transcatheter Uterine Artery Embolization CG-SURG-35 Intracytoplasmic Sperm Injection (ICSI) CG-SURG-36 Adenoidectomy CG-SURG-61 Cryosurgical Ablation of Solid Tumors Outside the Liver T CG-SURG-62 Radiofrequency Ablation to Treat Tumors Outside the Liver CG-SURG-63 Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure CG-SURG-70 Gastric Electrical Stimulation L8680 L8688 CG-SURG-71 Reduction Mammaplasty CG-SURG-73 Self-Expanding Absorptive Sinus Ostial Dilation C1726 CG-SURG-74 Total Ankle Replacement CG-SURG-76 Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement
24 T 0076T CG-SURG-78 Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies CG-SURG-79 Implantable Infusion Pumps CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants CG-SURG-82 CG-SURG-83 Bone-Anchored and Bone Conduction Hearing Aids Bariatric Surgery and Other Treatments for Clinically Severe Obesity L8614 L8619 L8627 L8628 S L8690 L8691 L8694 V SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG.00024
25 OTHER Bariatric Surgery and Other Treatments for Clinically Severe Obesity Mandibular/Maxillary (Orthognathic) Surgery T 0313T 0314T 0315T 0316T 0317T SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG.00024
26 CG-SURG-85 CG-SURG-87 Hip Resurfacing Nasal Surgery for the Treatment of Obstructive Sleep Apnea (OSA) (Including Radiofrequency Ablation of Nasal Turbinates for Nasal Obstruction with or without OSA) D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7995 D S SURG SURG SURG SURG SURG SURG.00074
27 SURG SURG SURG SURG SURG SURG C9749 SURG CG-SURG-88 Mastectomy for Gynecomastia SURG CG-SURG-90 Mohs Micrographic Surgery Add Add Add Add Add CG-SURG-92 Paraesophageal Hernia Repair Add Add Add Add Add Add Add Add Add Add Add Add Add Add Add Add CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit SURG Dysfunction CG-SURG-95 Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention L8679 L8680 L8686 C SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG SURG.00117
28 CG-TRANS-02 Kidney Transplantation
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34 he member s identification card. Service ct to change based on the contract ncy, failure to obtain preapproval prior to classified by lan members. Determine if preapproval is g the preapproval phone number printed on , Monday Friday, 8:00 a.m. 6:00. By clicking on the link above, you will be and security policies of the External Sites. d. rmined. would to ted length of stay d Blue Shield. SK website. 1/2019 as noted. hese codes will continue to be o. 1/1/2019
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41 9/1/2018 9/1/2018 Archive 1/1/2019 Archive 1/1/2019 Archive 1/1/2019 Archive 1/1/2019 Archive 1/1/2019
42 Archive 1/1/2019 Archive 1/1/2019 Archive 1/1/2019 Archive 1/1/2019 Archive 1/1/2019 Archive 1/1/2019 Archive 1/1/2019 Implementation Date
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45 m/goweb 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019
46 10/31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/2018
47 10/31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/ /31/2018
48 7/1/2019
49 10/31/ /31/2018
50 9/1/2018 4/1/2019 4/1/2019
51 7/1/2019
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54 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019
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60 3/1/2019 3/1/2019 3/1/2019 3/1/2019 3/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 3/21/2019 3/21/2019 3/21/2019 3/21/2019 3/21/2019 3/21/2019 3/21/2019 3/21/2019
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AIM Specialty Health
GA Standard Preapproval CODE List (06/01/18) Eligibility and benefits Eligibility and benefits can be verified by accessing the BCBSGa/BCBSHP web site bcbsga.com or by calling the number on the back of
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