1. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Anthem Serving Hoosier Healthwise and Healthy Indiana Plan State Sponsored Business Prior Authorization

2. 2 Physician is responsible for obtaining the preservice review for both professional and institutional services. Hospital and ancillary providers should always contact us to verify preservice review status. Authorization is not required when referring a member to an in network specialist. Authorization is required when referring to an out-of-network specialist. Nonparticipating providers seeing Anthem’s Medicaid members -All services require Prior Authorization. Check the Prior Authorization list regularly for any updates on services that require Prior Authorization. See the Prior Authorization Toolkit listed on our website: www.anthem.com

3. 3 Prior Authorization Contact Information: Phone:1-866-408-7187 FAX:1-866-406-2803 Form and Resource Tools available online: www.anthem.com Providers Spotlight  Anthem State Sponsored Programs  IN  Policies or Prior Auth Forms: Preservice Review Forms available, such as: Request for Preservice Review; Home Apnea Monitor; Home Oxygen; CPAP/BIPAP; Pediatric Formula; etc. See our website: Medical Policies and UM Clinical Guidelines. Note: Requests that do not appear to meet criteria are sent to an Anthem physician for medical necessity determination,

4. 4 Prior Authorization What to have ready when calling Utilization Management: Member name and ID number Diagnosis with ICD9 code Procedure with CPT code Date(s) of Service Primary Physician, Specialist, and Facility performing services Clinical information to support the request Treatment and discharge plans (if known)

5. 5 Prior Authorization Other Help Available: Retro Prior Authorization Review: If the service/care has already been performed, UM case will not be started. Send medical records in with the claim for review: Attn: Anthem Correspondence/Utilization Management Anthem Blue Cross and Blue Shield PO Box 6144 Indianapolis, IN 46206-6144 Benefits, Eligibility, or Claim information: Hoosier Healthwise Contact Customer Care at 1-866-408-6132. Healthy Indiana Plan Contact Customer Care at 1-800-553-2019.

6. 6 Prior Authorization Time Frames: Non-urgent reviews are completed within 14 calendar days from date of request. Urgent reviews are completed within 72 hours from the date of the request. Emergency services do not require prior authorization.

7. 7 Prior Authorization Questions