167821 Pw E167821
User Manual: 167821
Open the PDF directly: View PDF 
.
Page Count: 1
SEM 27 Medical Referral & Prior Authorization Process
February 2015
Published by:
Medical Referral & Prior Authorization Process
To request a medical referral or prior authorization (also known as pre-authorization, pre-certication,
pre-determination) from Utilization Management for a member, follow the process below:
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-Certication/Pre-Authorization Requirements
(for Local Plan members)
• Medical Policies and Clinical UM Guidelines
(for BlueCard Out-of-Area members)
• Pre-Certication/Pre-Authorization Requirements
(for BlueCard Out-of-Area members)
2. To verify a member’s eligibility and benets:
a) Use the Availity Web Portal- www.availity.com
b) Call the customer service number on the back of the
member’s ID card
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
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 benet 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
& Benets. 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.
c) www.anthem.com/ca > Providers > Enter > Answers@Anthem
• Utilization Management Case Intake Forms:
Medical Pre-Authorization Request
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.
