CurrentAnthemPolicy N/A

Out-of-Network Outpatient Behavioral Health Treatment Request - Coverage Criteria

Form and authorization process for out-of-network outpatient behavioral health providers to request authorization for Medi-Cal members when no contracted Anthem behavioral health provider is available; affects out-of-network BH providers servicing Anthem Medi-Cal members in NC.

Policy Summary

PayerAnthem

PolicyOut-of-Network Outpatient Behavioral Health Treatment Request - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionOut-of-network outpatient BH providers must complete and submit the authorization request form with member and provider identifiers, CPT codes, number/frequency of visits, treatment goals, and current risk assessment via the listed phone/fax.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

phone/faxsubmission contact

requiredform fields

includedrisk assessment

CPT/frequencytreatment request

Coverage Criteria

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Provider Actions & Submission Requirements

Prior Authorization

Submit authorization request

Out-of-network outpatient behavioral health providers must complete and submit the Anthem Out-of-Network Outpatient Treatment Request form for authorization. Phone: 888-831-2246. Fax: 855-473-7902. Facility/PCP referrals should use contracted Anthem BH providers when available; use this form only when an out-of-network provider is required.

Submit authorization request before services are rendered when possible.
Provide clear, legible forms — incomplete or illegible submissions will delay processing and may result in denial.

Note

Provider follow-up actions

Ensure the request includes completion of all applicable sections on the form and attachments described below. Retain copies of communications with the member's PCP and any consent forms for sensitive conditions (e.g., substance use, HIV) to support continuity-of-care justification.

Notify the member's PCP per Medi‑Cal requirements and document date of notification.
If the member has substance use and/or HIV diagnosis, include documented consent to release information if applicable.

Documentation Required

Required form documentation

The completed form must include specific member and provider identifiers, clinical history, and supporting documentation. Missing or illegible information will delay review and may lead to denial. Attach all relevant prior behavioral health/substance use treatment records, risk assessments, standardized assessment scores, and correspondence with the PCP.

Member identifiers: patient name, DOB, address, phone, Medi‑Cal ID, last authorization # (if any).
Provider identifiers: direct servicing provider name/credentials, physical address, provider email, phone, fax, NPI, Tax ID.
Reason for out-of-network request (e.g., in‑network not in area, language, specialty) and continuity-of-care explanation.
Prior BH/substance use history, hospitalizations, current substance/tobacco use details, DSM‑5/ICD‑10 diagnoses, and standardized assessment scores.
Document PCP communication: PCP name, phone, date last notified, and whether evaluation/treatment plan was shared.
Attach consents for release of information when required (substance use/HIV), medication history, and any prior authorization or county service records.

Background

The purpose of this form is to collect the clinical and administrative information Anthem needs to evaluate medical necessity and to coordinate outpatient behavioral health care for Medi‑Cal members receiving services out‑of‑network. The form requests identifying information, clinical history, treatment and discharge goals, current risk/lethality ratings, medication and psychiatric involvement, and the specific services requested so that authorization decisions can be made. Please note: incomplete or illegible forms will delay processing and may result in denial or delay of authorization.

Level of Care Criteria

Outpatient

Authorization for outpatient level of care is supported when the provider submits a complete outpatient authorization request containing the items below.

Outpatient authorization data: Authorization request must include requested services (individual/group therapy), total sessions requested, frequency, CPT codes, treatment goals and measurable assessments, current risk/lethality, and coordination with PCP/other providers.

Visit Limits & Requested Sessions

Individual or Group therapy — visit limits and request fields

Total sessions requestedProvider-entered total sessions requested for the treatment episode (field on form)

Services requestedIndividual therapy and/or Group therapy can be selected by provider (check boxes on form)

Frequency of visitsProvider-entered frequency of visits (field on form)

CPT codes and visits per codeProvider must list CPT codes and number of visits per code on the form

Estimated sessions to complete episodeProvider-entered estimated number of sessions to complete treatment episode (field on form)