Request for Prior Authorization - Mental Health Medications
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Governs prior authorization requests for mental health medications for members served by Anthem Blue Cross and Blue Shield programs listed (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging); applies to prescribing providers completing PA requests and submitting required clinical documentation.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Criteria
Medical necessity and documentation criteria
Covered when the provider completes the prior authorization form and documents the applicable prescribing situation plus answers to required clinical questions and medication history.
All of the following must be provided
ONE or more applicable prescribing situations (check all that apply)
- 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
- Two or more concurrent stimulant agents
- Completed provider and patient identifiers and prescriber attestation (form must be completed by the prescribing provider; all sections must be completed or the request will be returned).N/A
Include prescriber name, IN license number, NPI, signature, return fax/phone.
- If requesting retroactive prior authorization, mark the retroactive PA box and provide dates of service requested for retroactive eligibility; submit retroactive claim requests separately when dates of service are prior to 30 calendar days of submission, per instructions.
For any prescribing situation box selected, answer Questions 1–4 below
- Question 1: Is (are) the medication(s) prescribed for a DSM‑V diagnosis?Answer: Yes or No
- Question 2: Is (are) the medication(s) prescribed by, or in consultation with, a psychiatrist?Answer: Yes or No
- Question 3: Is the medication, or one of its counterparts, being tapered/cross‑tapered? Include anticipated duration of taper when applicable.Answer: Yes or No
- Question 4: Is there documentation that the patient has had a trial of each medication individually, at adequate dose and duration, and is improving more on the combination than on any one medication separately?Answer: Yes or No
- Provide requested medication details and full associated medication history, including requested medication name, strength, quantity, dosage regimen, diagnosis, date started, and prior/associated medications with same details; include clinical explanation/justification and attach progress notes or treatment plan if available.
Coding
| No codes listed |
Submission, Documentation, and Provider Guidance
Submission & documentation — complete PA form and fax to Prior Authorization of Benefits Center
Complete the prior authorization form in its entirety and fax to the Prior Authorization of Benefits Center. Use retail fax 844-864-7860 or medical injectable fax 888-209-7838. Include the prescriber's signature, return fax/phone, and mark the box if requesting retroactive PA with dates of service when applicable. Provide required clinical documentation and treatment history; all sections must be completed or the request will be returned. For member support or submission help, use the Provider Help Desk numbers listed for each program.
- Complete form in its entirety; prescribing provider must complete the form and sign.
- Fax to Prior Authorization of Benefits Center: retail 844-864-7860 or medical injectable 888-209-7838.
- Include return fax/phone and required clinical justification and treatment history.
- All sections must be completed or the request will be returned.
- Provider Help Desk contacts: 866-408-6132 (Hoosier Healthwise); 844-533-1995 (Healthy Indiana Plan); 844-284-1798 (Hoosier Care Connect); 833-569-4739 (Indiana PathWays for Aging).
Retroactive prior authorization — submit separately and include dates of service
If requesting retroactive claims (dates of service prior to eligibility determination but within established eligibility timelines), mark the retroactive PA box on the form, supply the date(s) of service requested for retroactive eligibility, and submit those retroactive PA requests separately from current PA requests per the form instructions.
- Mark the box labeled 'Mark box if requesting retroactive PA' and provide date(s) of service for retroactive eligibility.
- Submit retroactive claims (dates prior to eligibility determination but within established eligibility timelines) separately from current PA requests; current requests are dates of service 30 calendar days or less and going forward.
Contracted provider guidance — follow group authorization and claims processes
Providers contracted through an ACO, PMG, or IPA must follow their group's authorization, covered benefits, and claims submission practices; contact your group administrator or Anthem network representative with questions.
- Follow your group's guidelines and practices for authorization and claims submittal when serving Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, or Indiana PathWays for Aging.
- Contact your group administrator or Anthem network representative for process questions.
Definitions and Terms
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