Prior authorization is a requirement that Anthem Blue Cross may impose before you receive certain medical services or medications. It's not a denial of coverage—it's a step in the approval process designed to verify that a treatment meets the plan's medical necessity standards before you undergo the procedure or start a medication.
Understanding how this process works, when it applies, and what you can do if a request is denied helps you avoid unexpected costs and navigate your care more smoothly.
Prior authorization (also called precertification or preauthorization) is your insurance company's way of reviewing a proposed treatment in advance. Your doctor's office submits information about the service or medication to Anthem Blue Cross, which then evaluates whether it aligns with your plan's coverage rules and clinical guidelines.
The insurer is checking whether the treatment is:
If approved, you get a prior authorization number, which signals to providers and the insurer that the claim has been pre-reviewed. This doesn't guarantee payment, but it reduces the risk that the claim will be denied after you've already received care.
The specific services requiring prior authorization vary by plan type and coverage level. Commonly flagged categories include:
Your specific plan documents and the Anthem Blue Cross website or member portal will detail which services trigger the requirement for your coverage type.
Your healthcare provider's office usually handles this—they submit the authorization request on your behalf. However, you can request it yourself or ask your provider to expedite it.
When requesting prior authorization, have ready:
You can typically submit via:
Anthem Blue Cross typically responds within:
During holidays or high-volume periods, processing may take longer. If your treatment is time-sensitive, request expedited review explicitly.
A denial doesn't mean you can't receive the treatment—it means Anthem Blue Cross determined it doesn't meet coverage criteria under your plan. You have options:
Denials come with documentation explaining the reason. Understanding the specific objection makes your appeal more effective.
Whether prior authorization significantly impacts your care depends on:
| Factor | Impact |
|---|---|
| Your plan type | HMOs and PPOs have different authorization requirements; specialty plans may be stricter |
| Your provider's experience | Established networks often process requests faster than out-of-network submissions |
| Request completeness | Incomplete submissions cause delays and resubmissions |
| Service urgency | Emergency care usually bypasses authorization, but urgent nonemergency care may require expedited review |
| Your state's regulations | State insurance laws set minimum timelines and appeal rights |
Prior authorization is a standard part of insurance administration, not a red flag. But it does require proactive engagement—staying informed and involved helps prevent delays and unnecessary out-of-pocket surprises.
