Updated June 02, 2022
An Anthem (Blue Cross Blue Shield) prior authorization form is what physicians will use when requesting payment for a patient’s prescription cost. The form contains important information regarding the patient’s medical history and requested medication which Anthem will use to determine whether or not the prescription is included in the patient’s health care plan. Anthem has also made available a series of forms for specific medications which may provide more efficient service when making a request.
- Contact Anthem
- Specific Anthem Medications
How to Write
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.
Step 2 – In “Patient Information”, provide the patient’s full name, phone number, full address, date of birth, sex (m/f), height, and weight. Also, specify any allergies and give the name and phone number of the patient’s authorized representative (if applicable).
Step 3 – In “Insurance Information”, provide the primary and secondary insurance providers along with the corresponding patient ID numbers.
Step 4 – In “Prescriber Information”, specify the prescriber’s full name, speciality, and full address. Below that, write the name of the requester (if different than the prescriber) and supply the prescriber’s NPI number and DEA number. Lastly, give the name of an office contact person along with the corresponding phone number, fax number, and email address.
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, specify the date therapy started and the duration).
Step 6 – In “Medication / Medical and Dispensing Information”, describe how the patient paid for their medication (include the insurance name and prior authorization number).
Step 7 – In “Medication / Medical and Dispensing Information”, specify the following prescription details: dose/strength, frequency, length of therapy/number of refills, and quantity.
Step 8 – In “Medication / Medical and Dispensing Information”, indicate the administration method and administration location.
Step 9 – At the top of page 2, provide the patient’s name and ID number.
Step 10 – On page 2 (1), select yes or no to indicate whether the patient has tried other medications for their condition. If yes, provide the medication name, dosage, duration of therapy, and outcome.
Step 11 – On page 2 (2), list all diagnoses and provide the ICD-9/ICD-10.
Step 12 – On page 2 (3), provide any details supporting the request (symptoms, clinic notes, lab results, etc.).
Step 13 – The prescriber must provide their signature at the bottom of the form and the date of signing.
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. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.
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Behavioral health
Services billed with the following revenue codes ALWAYS require precertification:
| 0240–0249 | All-inclusive ancillary psychiatric |
| 0901, 0905–0907, 0913 and 0917 | Behavioral health treatment services |
| 0944–0945 | Other therapeutic services |
| 0961 | Psychiatric professional fees |
Pharmacy
Pharmacy prior authorizations can be requested through Availity.
You can also request prior authorization by calling:
Hours of operation: Monday-Friday, 8 a.m. to 8 p.m.
Hoosier Healthwise:
866-408-6132
Healthy Indiana Plan:
844-533-1995
Hoosier Care Connect:
844-284-1798
Fax:
Retail:
844-864-7860
Medical Injectables:
888-209-7838
Services billed with the following revenue codes ALWAYS require precertification:
| 0632 | Pharmacy multiple sources |
The following ALWAYS require precertification:
Elective services provided by or arranged at nonparticipating facilities
All services billed with the following revenue codes:
| 0023 | Home health prospective payment system |
| 0570–0572, 0579 | Home health aid |
| 0944–0945 | Other therapeutic services |
| 3101–3109 | Adult day and foster care |
Prior authorization - Phone
Utilization Management, Behavioral Health and Pharmacy
Hours of operation: Monday-Friday, 8 a.m. to 8 p.m.
Hoosier Healthwise:
866-408-6132
Healthy Indiana Plan:
844-533-1995
Hoosier Care Connect:
844-284-1798
Prior authorization - Fax
Physical health inpatient and outpatient services:
Fax
866-406-2803
Concurrent reviews for inpatient, skilled nursing facility, long-term acute care hospital and acute inpatient rehabilitation:
Fax
844-765-5156
Submission of clinical documentation as requested by the Anthem Blue Cross and Blue Shield outpatient Utilization Management department to complete medical necessity reviews for outpatient services such as DME, Home Health care, wound care, orthotics, and out-of-network requests should be faxed to 844-765-5157. For AIM-related CPT® codes, all requests are initiated by AIM Specialty Health®* online at //aimspecialtyhealth.com or by calling 844-767-8158. You may also access the Precertification Lookup Tool directly here.
* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.
Fax
844-765-5157
Related resources
- Medical Policies and Clinical UM Guidelines Search
- AIM Specialty Health Guidelines
- Universal Authorization Form
Documents
- DME Rental List
- Medical Necessity Code List
- Retail Pharmacy Prior Authorization Forms
- Medical Injectable Prior Authorization Form
- Synagis Prior Authorization Form
- Submit prior authorizations online with Interactive Care Review
- Behavioral Health outpatient authorization process
- Home Health wound care update
- Indiana Medicaid Prior Authorization Requirements List
Page Last Updated: 10/11/2021
Provider tools & resources
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- Precertification Lookup Tool
- Prior Authorization Requirements
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- Referrals
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- Electronic Data Interchange (EDI)
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