Anthem / Elevance Health Fertility Billing Guide
Anthem / Elevance Health is the second-largest US health insurer and the BCBS licensee in 14 states including California, New York, Georgia, and Ohio. Fertility coverage on Anthem plans is generally solid for fully-insured groups in mandate states. Prior authorization is managed through AIM Specialty Health in many markets — a key distinction that affects where you submit auth requests. Anthem has been expanding fertility benefits through employer partnerships, making benefits verification more critical than ever.
Key billing fact: Anthem operates as the BCBS licensee in 14 states. Uses AIM Specialty Health (an Anthem subsidiary) for prior authorization in many markets.
What Anthem Covers for Fertility Treatment
| Service | Coverage | Notes |
|---|---|---|
| Diagnostic infertility workup | ✓ Covered | Covered as medical benefit. Use N97.x or N46.x dx codes; avoid Z31.x as primary. |
| IUI | ✓ Covered | Covered on most plans; prior auth required in most states. Typical limit: 3–6 cycles. |
| IVF (fresh cycle) | ✓ Covered | Covered on fully-insured plans in mandate states. Self-funded ERISA plans may exclude. Lifetime dollar limits vary ($10k–$30k). |
| Frozen embryo transfer (FET) | ✓ Covered | Covered; many plans count each FET transfer against the cycle or dollar limit. |
| Egg freezing (elective) | ✗ Not Covered | Not covered on most plans. Medical necessity egg freezing (oncofertility) is covered with appropriate documentation. |
| Donor egg cycle | ✗ Not Covered | Typically excluded. A small number of large employer Anthem plans include donor egg riders. |
| PGT-A / PGT-M | ✗ Not Covered | Generally considered investigational on Anthem medical policies. PGT-M for known genetic disease may be considered on a case-by-case basis. |
| Sperm retrieval (TESA/TESE) | ✓ Covered | Covered as a surgical procedure when azoospermia is documented. AIM auth often required. |
| Fertility medications | ✓ Covered | Covered through pharmacy benefit. Confirm specialty pharmacy network — Anthem prefers its specialty pharmacy network. |
Prior Authorization Requirements
Submit to AIM Specialty Health if plan is AIM-managed. Include clinical summary, ovarian reserve labs, and prior treatment history.
Separate auth from retrieval. Include embryology report with embryo grade/PGT status.
Auth required in most Anthem states. May require documentation of 3–6 months of medically supervised infertility treatment.
Submit with detailed medical necessity letter. PGT-M approvals more likely than PGT-A. Always appeal PGT-A denials.
Typically bundled in IVF global; confirm with plan.
Submit as surgical procedure. Include semen analysis and documentation of azoospermia etiology.
Top Anthem Fertility Billing Denial Reasons
These are the most common reasons Anthem / Elevance Health denies fertility claims — and how to prevent each one.
How to avoid: Confirm at benefits verification whether AIM Specialty Health manages fertility auth. AIM and Anthem use different portals and phone lines.
How to avoid: Anthem fully-insured plans in mandate states must cover IVF. ERISA self-funded plans are exempt. Check the plan type — not just the insurance card — to confirm.
How to avoid: Anthem/AIM reviewers expect AMH, AFC, FSH day 3, semen analysis, and prior treatment history in the auth package. Missing any of these triggers an "additional information" request and delays.
How to avoid: Verify that your clinic is contracted with Anthem AND with AIM if AIM manages the fertility benefit. These networks are separate.
How to avoid: Direct patients to Anthem's preferred specialty pharmacy for fertility injectables. Out-of-network pharmacy claims for injectables are frequently rejected at the member level.
Anthem Fertility Billing Tips
Confirm AIM involvement before every new case
Call Anthem provider services or check the online portal to determine if AIM Specialty Health manages the fertility benefit. This single step prevents the most common Anthem denial type.
Use the Availity portal for Anthem eligibility
Availity is Anthem's preferred portal for eligibility, prior auth submission, and claims status. Real-time eligibility checks there show fertility benefit details including cycle limits and dollars used.
Build a strong auth package upfront
Anthem and AIM have detailed clinical criteria. Submit a complete package on first submission: diagnosis, AMH/AFC, FSH, semen analysis, cycle history, and physician attestation. This reduces the chance of an additional information request.
Track state-specific rules carefully
Anthem operates in 14 BCBS states with different state mandates. Rules for IVF cycles, age limits, and covered services differ by state. Build a reference sheet for each Anthem state where your patients are covered.
Appeal PGT denials with ASRM guidelines
Anthem's medical policy considers PGT-A investigational, but the policy allows for exceptions with documented clinical rationale. Submit ASRM Practice Committee Opinions on PGT-A as supporting evidence in appeals.
Anthem / Elevance Health Fertility Billing — Frequently Asked Questions
Is Anthem the same as Blue Cross Blue Shield?
Anthem / Elevance Health is the BCBS licensee in 14 states: California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, and Wisconsin. In those states, Anthem plans carry the BCBS logo. In other states, BCBS plans are managed by different independent licensees.
What is AIM Specialty Health and how does it affect fertility billing?
AIM Specialty Health is an Anthem subsidiary that manages prior authorization for specialty procedures — including fertility — on many Anthem employer plans. When AIM manages the fertility benefit, you must submit prior auth requests to AIM (not to Anthem directly). AIM has its own clinical criteria, portal (iExchange), and appeals process.
Does Anthem cover IVF in California?
Yes, for fully-insured Anthem Blue Cross plans in California — especially since SB 729 took effect January 1, 2025, requiring most fully-insured large group plans to cover IVF. Self-funded employer plans are exempt from SB 729. Verify whether the patient's plan is fully-insured or self-funded before confirming coverage.
How do I submit a prior auth to AIM for IVF?
Log into the AIM iExchange portal (available through the Availity portal or directly at aimspecialtyhealth.com). Create a new clinical certification request under "Infertility" or "Reproductive Endocrinology." Submit all required clinical information including the infertility diagnosis, ovarian reserve labs, prior treatment history, and the requested CPT codes.
What CPT codes does Anthem require for IVF prior auth?
Core IVF CPT codes include: 58970 (follicle puncture for oocyte retrieval), 89250 (culture of oocyte/embryo), 89272 (extended culture), 58974 (intrauterine embryo transfer), and 89352 (thaw and transfer of embryo). Submit all anticipated codes in the initial auth to avoid billing complications later.
Other Payer Guides
UHC requires prior authorization for virtually all ART procedures. Uses Optum as its fertility benefit manager on many employer plans.
Cigna uses LifeSource (a Cigna subsidiary) as its specialty fertility benefit manager on many plans. Fertility coverage is highly variable by employer plan.
Aetna has one of the clearest published fertility medical policies in the industry. Aetna owns CVS Caremark, which manages pharmacy benefits including fertility medications.
BCBS has 36 independent state licensees — each with its own fertility coverage policies and prior auth processes. The BlueCard program adds complexity when patients are treated out of their home state.
EasyRCM specializes in fertility billing for all major payers. Get a free audit to identify where Anthem denials are costing your practice revenue.