167821 Pw E167821
User Manual: 167821
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Published by: Medical Referral & Prior Authorization Process To request a medical referral or prior authorization (also known as pre-authorization, pre-certification, pre-determination) from Utilization Management for a member, follow the process below: 1. To determine if a service requires an authorization, use the following online tools: a) www.anthem.com/ca > Providers > Answers@Anthem > Tools & References • Prior Authorization List, which also links to Pre-Service Medical Review for Specialty Drugs • Medical-Surgical Clinical Data Submission Tools b) www.anthem.com/ca > Providers > Enter > Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements • Medical Policies and Clinical UM Guidelines (for Local Plan members) • Pre-Certification/Pre-Authorization Requirements (for Local Plan members) • Medical Policies and Clinical UM Guidelines (for BlueCard Out-of-Area members) • Pre-Certification/Pre-Authorization Requirements (for BlueCard Out-of-Area members) c) www.anthem.com/ca > Providers > Enter > Answers@Anthem • Utilization Management Case Intake Forms: Medical Pre-Authorization Request 2. To verify a member’s eligibility and benefits: a) Use the Availity Web Portal- www.availity.com b) Call the customer service number on the back of the member’s ID card 3. To request a prior authorization from Utilization Management: a) Fax: 866-815-0839 b) Call: Phone number on the back of the member’s ID card or • 800-274-7767 for Local Plan (Anthem Blue Cross) members • 866-470-6244 for National members • 800-451-6780 for CalPERS members Specialty Pharmacy Medical Management (SPMM - medical benefit only): call 866-580-5293 or fax 866-408-7195. To learn more about Specialty Pharmacy Medical Management, go to www.anthem.com/ca > Providers > Enter > Plans & Benefits. In the drop-down menu select Specialty Pharmacy Program. To access Request Forms, scroll to the bottom of this web page, click Anthem Blue Cross Pre-Service Medical Review for Specialty Drugs link, then click the link Pre-Service Medical Review Request Forms. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. SEM 27 Medical Referral & Prior Authorization Process February 2015
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