Anthem Prior Authorization List Update

Prior Authorization Required — Listed Services

Covered when prior authorization is obtained for listed services and the service is a covered benefit under the member's contract.

General: Preapproval required for listed services; member must be eligible and service must be covered under contract at time rendered

See list for specific services and vendor-managed programs; emergency admissions require plan notification within 24 hours

Admissions requiring prior authorization: Admissions that require prior authorization include elective admissions, emergency admissions, OB-related medical stays (OB complications, excludes childbirth), inpatient skilled nursing facility (SNF), long-term acute care facility (LTAC), rehabilitation facility admissions, and inpatient hospice respite care (CDHP plans only).

For emergency admissions Anthem requires plan notification within 24 hours

Maternity admissions (vaginal delivery > 2 days; Cesarean delivery > 4 days) require prior authorization when exceeding these length thresholds.Vaginal > 2 days; Cesarean > 4 days

Behavioral health and related services: Behavioral health services requiring authorization include inpatient admissions, intensive outpatient therapy, partial hospitalization, residential care, transcranial magnetic stimulation, applied behavioral analysis (ABA), and intensive in-home behavioral health services.

CDHP products: inpatient admissions require authorizations

Select procedures, devices, and tests: A broad set of procedures, devices, and diagnostic tests require prior authorization when listed, including but not limited to: bariatric surgery; mechanical circulatory assist devices (ventricular assist devices, percutaneous VADs, artificial hearts); radiofrequency/pulsed radiofrequency neurolysis for trigeminal neuralgia; reduction mammaplasty; sacral nerve stimulation; transcatheter heart valve procedures; various implantable and monitoring devices; advanced laboratory and sequencing tests; and other services enumerated in the Precertification/Prior Authorization List.

Refer to list for complete entries and responsible party (Anthem or Carelon) per item

Transplant services: All listed transplant inpatient admits require prior authorization, including hand, heart, kidney, liver, lung/double lung, multi-visceral, pancreas, simultaneous pancreas/kidney, and small bowel transplants; contact the Transplant Unit as indicated.

Contact Transplant Unit for inpatient admits (see policy contact information)

Vendor- or program-managed services: Certain services are managed by Carelon Medical Benefits Management or CarelonRx (specialty pharmacy) and require submission via Carelon portals or phone numbers listed; requirements for specialty pharmacy medications are found in Clinical Criteria in Pharmacy.

Follow vendor submission instructions for Carelon-managed programs

This preapproval list applies to Anthem local fully insured members and select self-insured (ASO) members only when their employer has purchased the applicable medical management program. It does not apply to BlueCard, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program (FEP) members. Providers will be notified at the time of a preapproval request whether preapproval is required for the member. If the employer has not purchased the program, preapproval is not required and clinical review will not be performed for that member. For questions, contact Provider Services using the phone number on the member's ID card.

Listed Services and Code Notes

Listed service/descriptive entries (no explicit CPT/HCPCS codes provided in this part)mixed

Mechanical circulatory assist devices	ventricular assist devices, percutaneous ventricular assist devices and artificial hearts
Metagenomic Sequencing for Infectious Diseases in the Outpatient Setting
Minimally invasive treatment of the posterior nasal nerve	to treat rhinitis
Moderate to deep anesthesia services for dental surgery in the facility setting
Multiplex autoantigen microarray testing for systemic lupus erythematosus
Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
Myocardial strain imaging
Nanoparticle-mediated thermal ablation
Noninvasive Imaging Technologies for the Evaluation of Skin Lesions
Observation stays - KY ACA individual only	Prior authorization required for KY

1–10 of 20

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Listed services (no codes provided in these chunks)mixed

Radiofrequency neurolysis and pulsed radiofrequency therapy for trigeminal neuralgia
Reduction mammaplasty
Remote devices for intermittent monitoring of intraocular pressure
Sacral Nerve Stimulation for Urinary Retention, Urinary Incontinence, and Fecal Incontinence
Specialty pharmacy medications	Requirements can be found at Clinical Criteria in Pharmacy; Responsible party = CarelonRx
Surface electromyography and electrodermal activity sensor devices for seizure monitoring
Transcatheter heart valve procedures
Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia or Gastroparesis
Transplant services - inpatient admits	Hand transplant; Heart transplant; Kidney transplant (eff. 8/1/21); Liver transplant; Lung or double lung transplant; Multi-visceral transplant; Pancreas transplant; Simultaneous pancreas/kidney; Small bowel transplant
Transplant services - outpatient services	Stem cell/bone marrow transplant (with or without myeloablative therapy); Donor leukocyte infusion; Uterine transplantation; Tissue transplant

1–10 of 25

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Maternity admission length thresholds (preapproval)

Vaginal delivery length thresholdAdmission for vaginal delivery requires preapproval if stay is more than 2 days

Cesarean delivery length thresholdAdmission for cesarean delivery requires preapproval if stay is more than 4 days

Context of thresholdApplies to maternity admissions listed on the Precertification/Prior Authorization List as a requirement for Anthem authorization

Responsible partyAnthem identified as responsible party for maternity admission preapproval per list entries

Related admission typesThresholds are listed alongside other admissions requiring preapproval such as elective and emergency admissions (emergency requires plan notification within 24 hours)

What Providers Must Do

Denial Risk

Risk of nonapproved services

Services that are not preapproved may be denied or result in reduced benefits for the member. Providers must obtain required preapproval before delivering services listed on the Precertification/Prior Authorization List to ensure services are covered and billed at network benefit levels. When preapproval is not obtained, claims may be processed at a lower benefit level or denied altogether.

Preapproval number appears on the back of the member's ID card.
Network physicians are responsible for obtaining preapproval for HMO, POS, PPO, and EPO members; out-of-network members are responsible for securing preapproval.
Codes/services not on the list may still require medical review prior to claims payment.

Prior Authorization

Carelon-managed prior authorization

Determine whether Carelon Medical Benefits Management manages the requested service and submit preapproval requests via Carelon's Provider Portal or by calling the Carelon preapproval number. Carelon manages certain programs (including advanced imaging, bariatrics, oncology, genetic testing, and others) on behalf of Anthem; follow Carelon submission rules and hours.

Submit requests online via Carelon Medical Benefits Management's Provider Portal (select your state).
Carelon phone: 866-714-1103, Monday–Friday, 8 a.m.–6 p.m. ET (or vendor number 877-291-0366 for certain vendor programs).
For specialty pharmacy medications, see CarelonRx (carelonrx.com) and Clinical Criteria in Pharmacy.

Prior Authorization

Transplant prior authorization

All listed transplant inpatient admits and related outpatient transplant services require preapproval. Contact Anthem's Transplant Unit for inpatient transplant admissions and coordination.

Anthem Transplant Unit phone: 888-574-7215 for transplant inpatient admits and coordination.
Inpatient transplants requiring authorization include heart, kidney, liver, lung (including double lung), pancreas, simultaneous pancreas/kidney, small bowel, multi‑visceral, hand transplant, and others listed on the transplant section.
Outpatient services such as stem cell/bone marrow transplant and donor leukocyte infusion also require prior authorization.

Prior Authorization

Prior authorization required for listed services

Many specific procedures, devices, therapies, and services on the Precertification/Prior Authorization List require preapproval. Verify the member's benefits and obtain authorization before providing these services to avoid claim denials or reduced payment.

Admissions (elective and emergency) — Anthem requires plan notification within 24 hours for emergency admissions.
Facility admissions including SNF, LTAC, rehabilitation, and specified maternity admission lengths.
Advanced/specialty procedures and devices (for example: bariatric surgery, mechanical circulatory support devices, transcatheter heart valve procedures, sacral nerve stimulation, reduction mammaplasty).
Specialty pharmacy medications are managed by CarelonRx — check Clinical Criteria in Pharmacy.
Behavioral health services (inpatient, partial hospitalization, intensive outpatient, residential, ABA, intensive in‑home services) require authorization.
Durable medical equipment, implantable devices, gene and cellular therapies, certain diagnostic and imaging procedures, and other items listed require preapproval.

Prior Authorization

Specialty pharmacy management

CarelonRx manages specialty pharmacy medications for applicable members; providers should follow pharmacy clinical criteria and submission instructions when requesting specialty drugs.

Specialty pharmacy requirements and clinical criteria are available in the Clinical Criteria in Pharmacy and via carelonrx.com.
For pharmacy-related questions, use CarelonRx resources or the Carelon portals referenced for medical benefit management.

Note

How to submit and where to find preapproval number

Check the member's ID card for the preapproval phone number and the preapproval number once issued. Submit requests and verify authorization status through Anthem's provider site or Carelon's Provider Portal as appropriate.

Preapproval number is listed on the back of the member's ID card.
Submit and verify authorizations via anthem.com > For Providers > [choose state] > Resources > Medical Policies & Clinical UM Guidelines, or via Carelon's Provider Portal.
Contact Provider Services using the number on the member's ID card for questions about Medical Policy applicability.

Note

Emergency admission notification

For emergency inpatient admissions, providers must notify the plan within 24 hours of the admission to meet notification requirements and preserve benefits.

Anthem requires plan notification within 24 hours for emergency admissions.

Note

Transplant contact

Contact the Transplant Unit directly for transplant inpatient admissions and coordination to ensure timely authorization and placement with an appropriate transplant program.

Transplant Unit phone: 888-574-7215.
Notify Anthem promptly for any inpatient transplant admission to coordinate benefits and facility placement.

OpenPayer

Precertification / Prior Authorization List

Preauthorization Requirements

Listed Services and Code Notes

What Providers Must Do

Policy Background

Key Definitions