What a prior authorization form does and when you need it
A prior authorization form is a request to Anthem Blue Cross asking them to review whether a specific medical service, procedure, or medication is medically necessary before you receive it. Anthem does not automatically cover every treatment your doctor recommends — they require advance approval for certain high-cost procedures, imaging scans, specialty drugs, and mental health services.
Your doctor's office typically submits this form on your behalf, not you. However, understanding what the form contains and what Anthem needs to approve it will help you follow up if there are delays. The form itself is called the Utilization Review Request Form or sometimes the Prior Authorization Request, depending on which Anthem plan you have.
You will encounter a prior authorization request when your doctor wants to order an MRI, recommend a specialist visit, prescribe a brand-name drug when a generic exists, or refer you to an inpatient hospital stay. Some routine office visits and lab tests do not require it. Your doctor's billing staff will know which services Anthem requires approval for under your specific plan.
Key Takeaways
- Your doctor's office submits the prior authorization form to Anthem, not you, but you should confirm they have sent it within one business day of your appointment request.
- Anthem typically responds within 24 to 72 hours for urgent requests and 5 to 10 business days for routine ones, though the timeline depends on how complete the form is.
- The form requires your member ID, the specific procedure code, medical records showing why the treatment is necessary, and your doctor's clinical notes.
- If Anthem denies the request, your doctor can appeal with additional medical evidence, and you have the right to request an independent external review.
- You can track the status of your prior authorization by calling Anthem's customer service number on the back of your insurance card.
What information Anthem needs on the form
The prior authorization form has two main sections: your information and the clinical information. On your side, Anthem needs your member ID number, date of birth, and contact phone number. This is straightforward — your doctor's billing staff will pull this from your insurance card.
The clinical section is where your doctor's office does the real work. They must list the specific procedure or service code (called a CPT code or HCPCS code), the reason your doctor is recommending it, and relevant medical history. For example, if you need an MRI of your knee, they will write the code for that specific MRI, note that you have a torn meniscus confirmed by physical exam, and include any imaging or test results that support the need.
Anthem also needs your doctor to explain why this particular treatment is the right choice — why an MRI instead of an X-ray, or why this brand-name medication instead of the generic version. The more detail your doctor provides about your medical condition and why standard treatments have not worked, the faster Anthem can approve it.
How your doctor's office submits the form
Your doctor's billing department will submit the form electronically through Anthem's online portal, by fax, or by phone, depending on your plan and the urgency of the request. Electronic submission is fastest — Anthem can receive and begin reviewing it within hours. Fax submissions may take longer because they require manual data entry on Anthem's end.
You should ask your doctor's office which method they are using and confirm that they have submitted it the same day you schedule your procedure or the day your doctor decides to prescribe the medication. Do not assume it has been sent just because your appointment is scheduled. Many delays happen because the form sits in a doctor's office for several days before anyone sends it.
If your procedure is urgent — for example, you need imaging to rule out a serious condition — tell your doctor's billing staff to mark it as urgent. Anthem has a faster review timeline for urgent requests, usually 24 hours instead of 5 to 10 business days.
How long Anthem takes to respond
Anthem's response time depends on whether the request is routine or urgent. For routine requests, expect 5 to 10 business days. For urgent requests, Anthem aims to respond within 24 hours, though it can take up to 72 hours. Business days do not include weekends or holidays, so a request submitted on Friday afternoon may not be reviewed until Tuesday.
The actual timeline also depends on how complete the form is. If your doctor's office submits it with missing information — for example, no clinical notes or no explanation of why the treatment is necessary — Anthem will contact them to ask for more details. This back-and-forth can add several days to the process.
You can check the status of your prior authorization by calling the customer service number on the back of your Anthem insurance card. Have your member ID and the date of service ready. The representative can tell you whether the request has been received, is under review, or has been approved or denied.
What happens if Anthem approves the request
If Anthem approves the prior authorization, they will send a letter to your doctor's office and often to you as well. This letter includes an authorization number and the date range during which the approval is valid. Keep this letter or note the authorization number — your doctor's office will use it when they bill Anthem for the service.
An approval means Anthem has determined the service is medically necessary and will cover it at the level specified in your plan. You will still owe your copay, coinsurance, or deductible, depending on your plan design. The prior authorization does not mean the service is free; it means Anthem will not deny the claim based on medical necessity.
The approval is usually valid for a set period — often 30 to 60 days. If you do not have the procedure or fill the prescription within that window, you may need to request a new prior authorization. Check the expiration date on the approval letter.
What to do if Anthem denies the request
If Anthem denies the prior authorization, your doctor's office will receive a denial letter explaining the reason. Common reasons include: the service is not covered under your plan, the condition does not meet Anthem's medical necessity criteria, or a less expensive alternative treatment should be tried first.
Your doctor can appeal the denial by submitting additional medical evidence — for example, documentation that you have already tried the alternative treatment and it did not work, or new test results that strengthen the case for the recommended service. An appeal goes to a medical reviewer at Anthem, usually within 5 to 10 business days.
If the appeal is also denied, you have the right to request an independent external review. This means an independent doctor (not employed by Anthem) will review your case. Your doctor's office can help you request this review, or you can contact Anthem directly using the number on your insurance card. There is no cost to you for an external review.
How to follow up if you do not hear back
If your procedure is scheduled and you have not heard whether the prior authorization was approved, call your doctor's office first. Ask them to confirm that they submitted the form and to provide you with the date they sent it. If they submitted it more than 10 business days ago for a routine request, or more than 3 business days ago for an urgent request, ask them to contact Anthem directly to check the status.
You can also call Anthem yourself using the number on your insurance card. Have your member ID, the date of service, and the name of the procedure ready. Ask for the status and whether any additional information is needed. If Anthem says they never received the form, ask your doctor's office to resubmit it when ready and confirm the submission method with Anthem before hanging up.
If your appointment is within a few days and the prior authorization is still pending, ask your doctor whether they can proceed without it. Some doctors will move forward at your own financial risk — meaning if Anthem denies it later, you may owe the full cost. Understand this risk before you agree.
Frequently Asked Questions
Do I have to fill out the prior authorization form myself?
No. Your doctor's office is responsible for completing and submitting the form to Anthem. However, you should confirm they have submitted it and follow up if you do not hear back within the expected timeframe. You can also call Anthem to check the status yourself.
What if my doctor says the procedure cannot wait for prior authorization?
If the situation is truly emergent — for example, you are in the emergency room — your doctor can proceed without prior authorization. Anthem will review the claim after the fact. However, if it is not a true emergency, getting prior authorization first protects you from unexpected bills if Anthem later denies the claim.
Can I request prior authorization for a medication my doctor has not prescribed yet?
No. Your doctor must decide to prescribe the medication first. Once they do, their office will submit the prior authorization request to Anthem. If you want to discuss whether a medication might require prior authorization before your doctor prescribes it, ask during your appointment.
What happens to my prior authorization if I change doctors?
The prior authorization is tied to your Anthem plan, not to your doctor. If you switch doctors, the new doctor can use the same authorization number to bill for the service, as long as the authorization has not expired. Provide the authorization letter to your new doctor's office.
How do I know which services need prior authorization?
Your doctor's office knows which services require prior authorization under your specific Anthem plan. You can also call Anthem's customer service number on your insurance card and ask whether a specific procedure or medication requires prior authorization before your appointment.