Prior Authorization Requirements
Our Interactive Care Reviewer (ICR) tool via Availity is the preferred method for submitting prior authorization requests, offering a streamlined and efficient experience for providers requesting inpatient and outpatient medical or behavioral health services for our members.
Anthem Blue Cross and Blue Shield Medicaid (Anthem) is available via phone or the ICR 24 hours a day, 7 days a week to accept prior authorization (PA) requests. You can access the ICR from the Availity home page:
- The ICR allows detailed text, photo images and attachments to be submitted along with your request.
- Providers can also use this tool to make inquiries on previously submitted PA requests, regardless of how they were sent (phone, fax, ICR or another online tool).
- To request or check the status of a PA request or decision, log in to Availity. Once logged in, select Patient Management | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.
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Prior authorization contact information for Anthem
Provider Services:
Hours: Monday to Friday from 8 a.m. to 6 p.m. ET (Interactive Voice Response (IVR) System available 24 hours a day, 7 days a week
Phone:
1-855-661-2028
Fax:
1-800-964-3627
Pharmacy department
Phone:
1-855-661-2028
Retail pharmacy fax:
1-844-879-2961
Medical injectables fax:
1-844-487-9289
The Medicaid-Approved Preferred Drug List (PDL) includes information such as mandatory generic requirements, PA, quantity limits, age limits or step therapy.
Pharmacy services billed with the following revenue codes always require prior authorization:
- 0632 — Pharmacy multiple sources
Behavioral health
Behavioral health services billed with the following revenue codes always require prior authorization:
- 0240 to 0249 — All-inclusive ancillary psychiatric
- 0901, 0905 to 0907, 0913, 0917 — Behavioral health treatment services
- 0944 to 0945 — Other therapeutic services
- 0961 — Psychiatric professional fees
Related resources
- Anthem’s Prior Authorization Lookup Tool Online can assist with identifying services requiring prior authorization or determining a code’s prior authorization requirements.
- You can also refer to the provider manual for information about services that require prior authorization.
- Prior Authorization Guidance Update
- Precertification Committee
- Pre-Certification of Requested Services – Core Process
- Changes to precertification approval notification process
- Chiropractic Services Prior Authorization Update November 2016
- Reminder for improved behavioral health precertification of services
- Chiropractic Services Prior Authorization Update January 2017
- Update: Radiology benefit management and cardiology
- Updated: Changes to precertification - physical, occupational and speech therapy codes
- Changes to precertification - physical, occupational and speech therapy codes
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Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Medicaid.