anthem blue cross prior authorization list anthem blue cross prior authorization list

2023 Regence health plans are Independent Licensees of the Blue Cross and Blue Shield Association serving members in Idaho, Oregon, Utah and select counties of Washington. or operation of any other website to which you may link from this website. AIM Specialty Health will transition to Carelon Medical Benefits Management Inc. Anthem Blue Cross and Blue Shield will begin reimbursing for services provided by unlicensed clinical behavioral health providers actively seeking licensure in New Hampshire. By using the website, you agree to our use of cookies to analyze website traffic and improve your experience on our website. To request or check the status of a prior authorization request or decision for a particular plan member, access our Interactive Care Reviewer (ICR) tool via Availity. Step 5 In Medication / Medical and Dispensing Information, specify the medication name and indicate whether or not the request is a new therapy or a renewal (if renewal, specifythe date therapy started and the duration). An Independent Licensee of the Blue Cross and Blue Shield Association, Summary of Benefits & Coverage Information, Sleep Testing and Therapy & Advanced Imaging, Confirm your specific treatment plan and medical necessity given your diagnosis, Determine if services are eligible for coverage, Assure your claims are processed accurately and timely, Save you from unnecessary medical expenses. Payments for services from a non-participating provider are generally sent to the member, except where federal or state mandates apply, or negotiated agreements are in place. Therefore, its important for you to know your benefits and covered services. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. February 2023 Anthem Provider News - Ohio, New ID cards for Anthem Blue Cross and Blue Shield members - Ohio, Telephonic-only care allowance extended through April 11, 2023 - Ohio, C1764 Event recorder, cardiac (implantable), E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized, E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment, L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each, L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each, L3310 Lift, elevation, heel and sole, neoprene, per inch, L3332 Lift, elevation, inside shoe, tapered, up to one-half inch, L3580 Ortho shoe add instep Velcro closure, L3610 Transfer of an orthosis from one shoe to another, caliper plate, new, L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing, L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new, L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified, L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf, L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf, L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf, L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf, L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise, L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type, L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf, L3913 HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment, L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. Use these lists to identify the member services that require prior authorization. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital . Please refer to the criteria listed below for genetic testing. Carelon Medical Benefits Management, Inc. You are invited: Advancing Mental Health Equity for Youth & Young Adults, Reminder: Updated Carelon Medical Benefits Management, Inc. Musculoskeletal Program effective April 1, 2023 - Site of care reviews, Carelon Medical Benefits Management (formerly AIM Specialty Health) Radiology Clinical Appropriateness Guidelines CPT code list update, Provider directory - annual audit for NCQA Accreditation, Statin Therapy Exclusions for Patients With Cardiovascular Disease/Diabetes HEDIS measures, March is National Colorectal Cancer Awareness Month, Reminder - Updated Carelon Musculoskeletal Program effective April 1, 2023: monitored anesthesia care reviews, Consumer payment option, Pay Doctor Bill, to terminate effective March 31, 2023, Pharmacy information available on our provider website, Controlling High Blood Pressure and Submitting Compliant Readings, Shared savings and transition care management after inpatient discharges. InteractiveCare Reviewer is a utilization management tool that lets you submit prior authorization requests and other clinical information quickly and easily. L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, L3925 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. It looks like you're in . Select Auth/Referral Inquiry or Authorizations. You can also refer to the provider manual for information about services that require prior authorization. Use of the Anthem websites constitutes your agreement with our Terms of Use. Your plan has a list of services that require prior authorization. Find care, claims & more with our new app. The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization/precertification form at anthem.com/medicareprovider > Providers > Provider Resources > Forms and Guides. View medication policies and pre-authorization requirements. We look forward to working with you to provide quality service for our members. Prior authorization contacts vary for Shared Administration groups.View the Shared Administration contact list for details. In Indiana: Anthem Insurance Companies, Inc. We currently don't offer resources in your area, but you can select an option below to see information for that state. Below that, write the name of the requester (if different than the prescriber) and supply the prescribers NPI number and DEA number. To learn more read Microsoft's help article. color, national origin, age, disability, sex, gender identity, or sexual orientation. Typically, we complete this review within two business days, and notify you and your provider of our decision. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. | Blue Cross of Idaho retains the right to review the medical necessity of services, eligibility for services and benefit limitations and exclusions after you receive the services. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. State & Federal / Medicare. The Blue Cross name and symbol are registered marks of the Blue Cross Association. ), 0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed), 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure. The formcontains important information regarding the patients medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patients health care plan. Prior authorization suspension for Anthem Ohio in-network hospital transfers to in-network skilled nursing facilities effective December 20, 2022 to January 15, 2023: Prior authorization suspension - In-network hospital transfers to In-network SNFs . In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Weve provided the following resources to help you understand Anthems prior authorization process and obtain authorization for your patients when its required. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. You can find the number on the back of your ID card, or you can write to us at the following address: Appeals and Grievance CoordinatorBlue Cross of IdahoPO Box 7408Boise, ID 83707. You understand and agree that by making any Have you reviewed your online provider directory information lately? Polski | The CarelonRx member services telephone number is 833-279-0458. Sep 1, 2021 Contact 866-773-2884 for authorization regarding treatment. However, if you receive services that are not medically necessary from a provider not contracting with Blue Cross of Idaho, you may be responsible for the entire cost of the services. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. The team reviews the requested service(s), determines if it is medically necessary and if the service is covered under your insurance plan. Step 8 In Medication / Medical and Dispensing Information, indicate the administration method and administration location. Prior Authorization Medication management With input from community physicians, specialty societies, and our Pharmacy & Therapeutics Committee, which includes community physicians and pharmacists from across the state, we design programs to help keep prescription drug coverage affordable. In Ohio: Community Insurance Company. Medical Policy and Clinical Guideline updates are available on our provider website, AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List update, Enhancing Provider News website and email communications, Helping to reduce delays when submitting attachments: Make sure your correspondence includes one of these elements, Updates to AIM Specialty Health Advanced Imaging Clinical Appropriateness Guidelines, Specialty pharmacy updates - February 2023, City of Manchester Offers Medicare Advantage Option - New Hampshire, Name change announcement: myNEXUS will transition to Carelon Post Acute Solutions on March 1, 2023, 2023 FEP benefit information available online, Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list (Fylnetra), Telephonic-only care allowance extended through April 11, 2023, Anthem Blue Cross and Blue Shield local precertification change in New Hampshire, Updates to AIM Specialty Health Radiation Oncology Clinical Appropriateness Guidelines, New specialty pharmacy medical step therapy requirements, Anthem Blue Cross and Blue Shield expands specialty pharmacy precertification list, Notification regarding reimbursement changes to COVID-19 laboratory services codes, Submitting prior authorizations digitally through Interactive Care Reviewer, Outpatient facility revenue code billing requirements, AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT code list update, Update: AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List, Updates to AIM Specialty Health Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines, Updates to AIM Specialty Health Musculoskeletal - Interventional Pain Management Clinical Appropriateness Guidelines, Updates to AIM Specialty Health Cardiac Clinical Appropriateness Guidelines - Material adverse change, Medical policy and clinical guideline updates available on our provider website, Federal Employee Program observation conversion for musculoskeletal cases, Remittance advice message enhancements: Providing clear descriptions and actionable next steps, Childhood Immunization Status and Lead Screening in Children for HEDIS, Attention lab providers: COVID-19 update regarding reimbursement, December 2022 Provider Newsletter - New Hampshire, Important information about utilization management, IngenioRx will become CarelonRx on January 1, 2023, Reimbursement policy retirement: Acupuncture Billed with Evaluation and Management - Professional, Reimbursement policy update: Treatment Rooms with Office Evaluation and Management Services - Facility, Reimbursement policy update: Bundled Services and Supplies - Professional, Manchester School District in New Hampshire moves to the Medicare Advantage plan with Anthem Blue Cross and Blue Shield, 2023 Medicare Advantage service area and benefit updates, Signature requirements for laboratory orders or requisitions, Reminder - updated AIM Musculoskeletal program effective January 1, 2023 - site of care reviews, Specialty pharmacy updates - December 2022, AIM Specialty Health Genetic Testing Clinical Appropriateness Guidelines CPT Code List update, Member assessment of PCP after-hours messaging in 2022, Members assessment of behavioral healthcare after-hours messaging in 2022, CAA: Timely updates help keep our provider directories current, Clinical practice and preventive health guidelines available on anthem.com, Pharmacy information available on the provider website, PCP searches in Find Care - New Hampshire, Support documentation for AIM prior authorization requests, November 2022 Provider Newsletter - New Hampshire, Claims status message enhancements: providing clear descriptions and actionable next steps, Submit digital attachments within seven-calendar days for claims filed with a PWK segment indicator, You can now submit one electronic claim dispute for multiple claims and access correspondence digitally, too, Visit the Provider Learning Hub to view our latest learning opportunities, Correction to reimbursement policy: Place of Service - Facility, Transition to AIM Specialty Health Perirectal Hydrogel Spacer for Prostate Radiotherapy Clinical Appropriateness Guideline, Medical policy and clinical guideline updates available on anthem.com, Medical drug benefit Clinical Criteria updates, Post office boxes being retired because of low usage, Specialty pharmacy updates - November 2022, CAA: Keep your provider directory information up to date, Information from Anthem for Care Providers about COVID-19 - RETIRED as of November 8, 2022, COVID-19 Information - New Hampshire - Publication RETIRED as of November 8, 2022, Register for our upcoming CME webinar about low back pain management, CME webinar about low back pain management - New Hampshire, October 2022 Provider Newsletter - New Hampshire. 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L3927 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (for example, static or ring type), may include soft interface material, prefabricated, L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system, L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee, L5645 Addition to lower extremity, below knee (BK), flexible inner socket, external frame, L5649 Addition to lower extremity, ischial containment/narrow M-L socket, L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each, 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed, 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure. . Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). This tool does not reflect benefits coverage, Access eligibility and benefits information on the, Use the Prior Authorization Lookup Tool within Availity. In Kentucky: Anthem Health Plans of Kentucky, Inc. You can also visit bcbs.com to find resources for other states It looks like you're outside the United States. Located in neighborhoods all over the country, CareMore Health Care Centers combine a variety of different specialty services under one roof. Visit Anthem.com to learn more about how we coordinate our medical and pharmacy benefits, review our drug lists, submit prior authorization requests, and more. Obtaining a prior authorization from Blue Cross of Idaho prevents this frustration. In Connecticut: Anthem Health Plans, Inc. You can also visit bcbs.com to find resources for other states. Anthem partners with health care professionals to close gaps in care and improve members overall heath. Find a Care Center. Prior authorization is required for surgical services only. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In the case of an emergency, you do not need prior authorization. In Kentucky: Anthem Health Plans of Kentucky, Inc. Premera Blue Cross complies with applicable federal and Washington state civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, If yes, provide the medication name, dosage, duration of therapy, and outcome. Prior authorization requirements will be added for the following codes: Not all prior authorization requirements are listed here. View tools for submitting prior authorizationsfor Medicare Advantage members. | It is a pre-service determination of medical necessity based on information provided to Blue Cross of Idaho at the time the prior authorization request is made. the content of any other website to which you may link, nor are ABCBS or the ABCBS Parties liable or responsible The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. If you choose to access other websites from this website, you agree, as a condition of choosing any such Prior Authorization Contact Information Providers and staff can also contact Anthem for help with prior authorization via the following methods: Utilization Management (UM) for Medi-Cal Managed Care (Medi-Cal) Phone: 1-888-831-2246 Hours: Monday to Friday, 8 a.m. to 5 p.m. Fax: 1-800-754-4708 Effective February 1, 2019, CareFirst will require ordering physicians to request prior authorization for molecular genetic tests. Anthem has also made available a series of forms for specific medications which may provide more efficient service when making a request. Check whether a prior authorization is needed Check the status of a prior authorization This information is also available in other ways to people with disabilities by calling customer service at (651) 662-8000 (voice), or 1-800-382-2000 (toll free). Step 11 On page 2 (2), list all diagnoses and provide theICD-9/ICD-10. You are about to leave regence.com and enter another website that is not affiliated with or licensed by the Blue Cross Blue Shield Association. The primary coverage criteria of certain services must be established through a prior Approval or pre-authorization process before they can be performed. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. As of November 8, 2022, THIS DOCUMENT WILL NO LONGER BE UPDATED. To request authorizations: From the Availity home page, select Patient Registration from the top navigation. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), whichunderwrites or administersthe PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation (Compcare) underwritesor administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers Well Priority HMO or POS policies. Italiano | In Ohio: Community Insurance Company. of all such websites. URAC Accredited - Health Plan with Health Insurance Marketplace (HIM) - 7.3, URAC Accredited - Health Utilization Management - 7.4, Member forms - Individual and family plans, Coverage policy and pre-certification/pre-authorization, Approval information for radiological services, Medicare Advantage Prior Authorization Request Form, Part B Medication Prior Approval Request Form, Check deductible and out-of-pocket totals. This tool is for outpatient services only. On January 1, 2021, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for codes below. Choose your location to get started. Step 4 In Prescriber Information, specifythe prescribers full name, speciality, and full address. The Internet Explorer 11 browser application will be retired and go out of support on June 15, 2022. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. CareMore Health is a leading primary care provider that specializes in chronic and complex conditions. In some cases, we require more information and will request additional records so we can make a fully informed decision. View requirements for Basic Option, Standard Option and FEP Blue Focus. In Ohio: Community Insurance Company. | Anthem Blue Cross and Blue Shield Medicaid is the trade name of Anthem Kentucky Managed Care Plan, Inc., independent licensee of the Blue Cross and Blue Shield Association. Updated June 02, 2022. Step 3 In Insurance Information, provide the primary and secondary insurance providersalong with the corresponding patient ID numbers. By filling out the form completely and with as much information as possible, you can be sure we have the information to process your request timely. Healthcare Effectiveness Data and Information Set (HEDIS), Early and Periodic Screening, Diagnostic and Treatment (EPSDT). If we deny your request for coverage or you have questions regarding your prior authorization, please call Blue Cross of Idahos Customer Service. Copyright 2001-2023 Arkansas Blue Cross and Blue Shield. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Call Provider Services at 1-800-450-8753 (TTY 711) After hours, verify member eligibility by calling the 24/7 NurseLine at 1-800-300-8181 To request authorizations: From the Availity home page, select Patient Registration from the top navigation. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Medicaid. You further agree that ABCBS and its Anthem is available via the Interactive Care Reviewer (ICR) in Availity 24/7 to accept emergent admission notification. Other Blue Plans pre-authorization requirements may differ from ours. Prior authorization helps address the issue of rising healthcare costs by keeping procedures and services that are not medically necessary from being performed. Some procedures may also receive instant approval. Medical Policies and Clinical UM Guidelines, HEDIS (The Healthcare Effectiveness Data & Information Set), Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Medi-Cal Managed Care and Major Risk Medical Insurance Program Provider Manual. Online - The AIM ProviderPortal is available 24x7. Oct 1, 2020 In the event of an emergency, members may access emergency services 24/7. We also want to ensure you receive the right technology that addresses your particular clinical issue. Please refer to Availity Essentials portal, Arkansas Blue Cross Coverage Policy or the members In Maine: Anthem Health Plans of Maine, Inc. may be offered to you through such other websites or by the owner or operator of such other websites. Medical Policy and Prior Authorization for Blue Plans. Type at least three letters and we will start finding suggestions for you. In Indiana: Anthem Insurance Companies, Inc. Step 6 In Medication / Medical and Dispensing Information, describe how the patient paid fortheir medication (include the insurance name and prior authorization number). You can also visit, Standard Local Prior Authorization Code List, Standard Prior Authorization Requirements, SHBP Precertification Procedure Codes Sheet, SHBP Co-pay/Co-insurance Waiver Medication List. Anthem Blue Cross Blue Shield: Health Insurance, Medicare & More Stay Covered When Medicaid Renewals Begin Medicaid renewals will start again soon. Or if you are calling about a specific case, they will direct your call to the appropriate prior authorization staff. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Connecticut: Anthem Health Plans, Inc. There is a list of these services in your member contract. This helps address the issue of rising healthcare costs by keeping procedures and services that are not medically necessary from being performed. Register today for the Advancing Mental Health Equity for Youth & Young Adults forum hosted by Anthem Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on March 15, 2023. The resources for our providers may differ between states. As healthcare costs go up, health insurance premiums also go up to pay for the services provided. Federal Employee Program. Prior authorization requests are submitted on different websites for Individual and non-Individual plan members (groups, associations, etc.). In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Step 1 At the top of the form, supply the plan/medical group name, plan/medical group phone number, and plan/medical group fax number. . website and are no longer accessing or using any ABCBS Data. We've provided the following resources to help you understand Anthem's prior authorization process and obtain authorization for your patients when it's required. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Inpatient services and nonparticipating providers always require prior authorization. Step 2 In Patient Information, provide the patients full name, phone number, full address, date of birth, sex (m/f), height, and weight. Do you offer telehealth services? | In the event that the emergency room visit results in the members admission to the hospital, providers must contact Anthem within one business day following admission or post-stabilization. Prior authorization is not a guarantee of payment. Use the Prior Authorization Lookup Tool within Availity or Call Provider Services at 1-855-661-2028. Information about COVID-19 and your insurance coverage. They may request or review medical records, test results and other information so they understand what services are being performed and are able to make an informed decision. In the case of a medical emergency, you do not need prior authorization to receive care. Type at least three letters and well start finding suggestions for you. Prior to surgical treatment of gender dysphoria in FEP members, you must submit a treatment plan, including all surgeries planned, and the estimated date each will be performed. An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient's prescription cost. View pre-authorization requirements for UMP members. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), whichunderwrites or administersthe PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation (Compcare) underwritesor administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers Well Priority HMO or POS policies.