Prior Authorization Requirements
Prior authorization tool
To request or check the status of a prior authorization request or decision, access our Interactive Care Reviewer (ICR) tool via Availity. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate.
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Physical Health
If you are unable to submit the request online through the Availity Portal , please download and complete the Prior Authorization Form , then fax your request to 1-800-964-3627.
Behavioral Health
Services billed with the following revenue codes always require prior authorization:
- 0240–0249 — All-inclusive ancillary psychiatric
- 0901, 0905–0907, 0913, 0917 — Behavioral health treatment service
- 0944–0945 — Other therapeutic services
- 0961 — Psychiatric professional fees
If you are unable to submit the request online through the Availity Portal, please fax requests to:
Inpatient — 1-877-434-7578
Outpatient — 1-866-877-5229
Pharmacy
Check out our Preferred Drug List (PDL) .
Services billed with the following revenue code(s) always require prior authorization:
0632 — Pharmacy multiple sources
Long-term services and supports
Providers needing an authorization should call 1-844-462-0022 .
The following always require prior authorization:
Elective services provided by or arranged at nonparticipating facilities
All services billed with the following revenue codes:
0023 — Home health prospective payment system
0570–0572, 0579 — Home health aide
0944–0945 — Other therapeutic services
3101–3109 — Adult day and foster care
Related information
Summit Community Care utilizes Anthem prior authorization criteria for the following medications:
Medicaid
Please refer to the Preferred Drug List (PDL) when prescribing for our members. This guide does not contain a complete list of drugs; rather, it lists the preferred drugs within the most commonly prescribed therapeutic categories.
Though most medications on the PDL are covered without prior authorization, a few agents will require you to contact our Pharmacy department for authorization.
Please refer to the Pharmacy tab listed under Resources for more information regarding upcoming PDL changes.
For prior authorization criteria, please visit Pharmacy Information.
- Prior authorization requirement for wheelchair components or accessories
- Prior authorization requirements for orthotics
- Prior authorization requirements for Chimeric antigen receptor T-cell therapy
- Prior authorization requirements for lower extremity vascular intervention
- Prior authorization requirements for services
- Prior authorization requirements for Jevtana (cabazitaxel)
- LTSS/Physical Health Prior Authorization Form