Anthem Elevance Prior Authorization
Anthem Elevance Prior Authorization: Overview
Anthem Elevance (formerly Anthem) requires prior authorization for 750+ procedures, medications, and services. Authorization confirms medical necessity and coverage eligibility before service delivery. Submit via providers.anthem.com or Availity. Urgent requests receive decisions within 72 hours. Routine requests process within 5–7 business days. Approvals include authorization number and validity dates to include on claim submissions.
Key Requirements
- Member ID, group number, and active policy effective date.
- Procedure or service code (CPT, HCPCS code).
- Clinical documentation supporting medical necessity (clinical notes, imaging, test results).
- Diagnosis codes (ICD-10) justifying the requested service.
- Provider credentials (NPI, specialty, tax ID).
- Facility information if service is facility-based (hospital, ambulatory surgery center).
Submission Methods & Timeline
- Via Availity: Log into your Availity account, select "Anthem," choose "Prior Authorization," enter member and procedure details, attach clinical documentation. Integration with most EHR systems.
- Via provider portal: Log into providers.anthem.com, select "Submit Prior Authorization," complete form with patient and clinical details.
- Urgent requests: Call Anthem Elevance authorization line (number on member ID). Verbal authorization followed by written confirmation. 72-hour turnaround.
- Receive decision: Approval or denial posted in portal or returned via phone. Track status in real time via Availity or provider portal.
Common Denials
| CARC Code | Reason | Action |
|---|---|---|
| CO-16 | Claim lacks required documentation | Resubmit authorization with complete clinical records, imaging, and medical justification. |
| CO-45 | Claim not submitted on proper HCFA form or clearinghouse format | Verify correct claim form format. Resubmit with proper claim documentation. |
| CO-197 | Non-covered service or excluded benefit | Check member's plan for benefit exclusions. Inform member of out-of-pocket responsibility. |
Appeal & Reconsideration
If prior authorization is denied, request reconsideration within the deadline specified in your state (60–365 days from denial). Submit additional clinical evidence or corrected information. File formal appeal if reconsideration is denied. Include physician attestation, peer-reviewed literature, and clinical justification. Anthem Elevance responds to routine appeals within 30 days and urgent appeals within 72 hours.
Common Questions
Can I submit prior authorization via Availity?
Yes. Availity is the preferred method. Log into your Availity account, select Anthem Elevance, and submit prior authorization. Most EHR systems integrate with Availity for faster submission.
What is the turnaround time for Anthem Elevance prior authorization?
Urgent requests: 72 hours. Routine requests: 5–7 business days. Call the authorization line for urgent verbal decisions.
What do I do if Anthem Elevance denies prior authorization?
Request reconsideration with new clinical information (state deadline: 60–365 days from denial). If denied again, file formal appeal with physician attestation and peer-reviewed evidence.
Altair checks Anthem Elevance requirements before submission . flagging missing authorizations and coding mismatches in real time. See how Altair works.
This reference is for informational purposes. Payer policies change frequently. Always verify against Anthem Elevance's current provider documentation. Last updated: 2026-03-16.