CurrentAnthemPolicy INBCBS-CD-064008-24-SRS63688

Request for Prior Authorization - Mental Health Medications

A fillable prior authorization form governing requests for mental health medication authorizations for Anthem members in Indiana programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging); must be completed by the prescribing provider and faxed to the designated PA center. Affects prescribing providers and administrative staff submitting PA requests.

Policy Summary

PayerAnthem

PolicyRequest for Prior Authorization - Mental Health Medications

Policy CodePolicy INBCBS-CD-064008-24-SRS63688

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete the form in its entirety (by the prescribing provider) and fax to the Prior Authorization of Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2fax numbers for PA submission (retail and medical injectable)

4phone numbers for provider/member support listed

5concurrent medication scenario checkboxes

1state-specific governance (Indiana Medicaid)

Prior Authorization Clinical Criteria

PA clinical and documentation criteria

When requesting authorization, providers must complete sections and satisfy the following clinical criteria where applicable:

ALL of the following

Concurrent medication scenarios
- Two or more concurrent antipsychotic agents
- Antipsychotic use at lower than minimum effective dose
- Two or more concurrent sedative hypnotic and/or benzodiazepine agents
- Two or more concurrent SSRI or SNRI agents

Policy Summary

PayerAnthem

PolicyRequest for Prior Authorization - Mental Health Medications

Policy CodePolicy INBCBS-CD-064008-24-SRS63688

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete the form in its entirety (by the prescribing provider) and fax to the Prior Authorization of Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).

SourceLink

On This Page

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Coding and Retroactive Submission

No billing or procedure codes providedmixed

No codes listed

Retroactive PA submission window instruction

InstructionSubmit PA requests for retroactive claims (dates of service prior to eligibility determination, but within established eligibility timelines) separately when dates of service are prior to 30 calendar days of submission; submit current PA requests for dates of service 30 calendar days or less and going forward.

Form checkboxMark the form checkbox if requesting retroactive PA and provide the date(s) of service requested for retroactive eligibility.

Who completes formThe form must be completed by the prescribing provider; all sections must be completed or the request will be returned.

Submission Requirements and Provider Responsibilities

Prior Authorization

Submission and required content

Complete the form in its entirety; the form must be completed by the prescribing provider and faxed to the Prior Authorization of Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable). Mark the retroactive PA box and provide dates of service when requesting retroactive authorization. Submit retroactive PA requests for dates of service prior to eligibility determination (but within established eligibility timelines) with dates of service prior to 30 calendar days of submission separately from current PA requests (dates of service 30 calendar days or less and going forward).

Fax retail PA to 844-864-7860; medical injectable PA to 888-209-7838.
Mark the checkbox labeled 'Mark box if requesting retroactive PA' and list date(s) of service.
Submit retroactive claims with dates of service prior to 30 calendar days of submission separately from current PA requests.

Documentation Required

Clinical documentation checklist

Ensure the medical record documents that the medication(s) are prescribed for a DSM-5 diagnosis, whether they were prescribed by or in consultation with a psychiatrist, if a taper/cross-taper is occurring and its anticipated duration, and that trials of each medication individually at adequate dose and duration have been documented with evidence the combination is superior. Include a thorough clinical explanation/justification and associated medication history; a current plan of treatment and progress notes may be requested.

Document DSM-5 diagnosis for the prescribed medication(s).
Indicate if prescribed by or in consultation with a psychiatrist.
If tapering/cross-tapering, document anticipated duration.
Document trials of each medication individually at adequate dose and duration and that the patient improves more on the combination than on individual agents.
Provide clinical explanation/justification and associated medication history; be prepared to supply treatment plan and progress notes if requested.

Prior Authorization

Contracted provider guidance

If you are contracted to serve Anthem members through an ACO, PMG, or IPA, follow your group's authorization, covered benefits, and claims submission practices; contact your group administrator or Anthem network representative with questions.

Group practices include but are not limited to authorization and claims submission guidelines.
Contact the group administrator or Anthem network representative for questions.

Definitions and Forms

Retroactive PA

DefinitionRetroactive PA: a prior authorization request for dates of service that occurred prior to eligibility determination but within established eligibility timelines.

How to indicateMark the 'requesting retroactive PA' checkbox on the form and list the date(s) of service requested for retroactive eligibility.

Submission timingSubmit retroactive claims with dates of service prior to 30 calendar days of submission separately from current PA requests (dates of service 30 calendar days or less and going forward).

Return riskIncomplete forms will be returned — ensure all sections are completed and the prescribing provider signs the form.

Indiana Medicaid Mental Health Quality Advisory Committee Medical Necessity Review Form

Form nameIndiana Medicaid Mental Health Quality Advisory Committee Medical Necessity Review Form

PurposeDocument requested medication, strength, quantity, dosage regimen, diagnosis, start date, and associated medication history to support medical necessity review.

Required contentProvide thorough clinical explanation/justification; a current plan of treatment and progress notes may be requested for documentation.

Medication history fieldsSections capture requested medication and up to several associated prior medications with strength, quantity, dosage regimen, diagnosis, and date started.