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  • Anthem Prior Authorization Form For Procedures

Get Anthem Prior Authorization Form For Procedures

Tient Date of Birth: Contact Name: Hospital Contact Phone #: Dates of Service: MD's office (check one) Fax Number: From: To: Admit Date: Diagnosis Code:* Procedure Code (CPT code):* *In order to expedite the review of this fax request, please provide the diagnosis code and CPT code for the procedure. Provider's Name: (First Name) (Last Name) Provider's Tax ID #: Provider's Phone #: Provider contracted with Blue Cross/Blue Shield Association Yes No Yes No Hospital or Facility Nam.

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For all other precertification requests (including all elective inpatient or outpatient services), please fax to: 1-800-964-3627.

By Phone: Call the number on the back of the member's ID card or dial 800-676-BLUE (2583) to speak to a Provider Service representative.

By Phone: Call the number on the back of the member's ID card or dial 800-676-BLUE (2583) to speak to a Provider Service representative.

How to access and use Availity Authorizations: Log in to Availity. Select Patient Registration menu option, choose Authorizations & Referrals, then Authorizations. Select Payer BCBSIL, then choose your organization. Select a Request Type and start request. Review and submit your request.

Hours: Monday to Friday, 8 a.m. to 5 p.m. Behavioral Health: For prior authorization requests specific to behavioral health, please fax requests to 1-855-473-7902 or email Medi-calBHUM@wellpoint.com.

For all other precertification requests (including all elective inpatient or outpatient services), please fax to: 1-800-964-3627.

Please fax your request with substantiating clinical information to 1-877-348-2251.

Please fill out the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form and fax it to (844) 474-3347.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232