Anthem blue cross blue shield medication prior authorization form

Blue Cross Complete of Michigan's self-service tools are valuable resources that can assist you in providing the highest quality of care to our members.

Provider directories

Drug formulary

A comprehensive drug list for Blue Cross Complete can be accessed and reviewed in two ways:

The searchable version of the drug list provides additional details regarding quantity limits, prior authorizations or other coverage details not available on the printable version. This includes guidance for obtaining specialty medications.

For pharmacies

The PerformRx Pricing Administration Department calculates generic Maximum Allowable Cost and money paid to participating pharmacies. MAC prices are updated each week. To ask for a MAC pricing review, email the PerformRx Pricing Administration Department. You can also call PerformRx Pharmacy Provider Services at 1-888-989-0057.

Prior Authorization Lookup

Find out if a service needs prior authorization. Type a Current Procedural Terminology, or CPT, code or a Healthcare Common Procedure Coding System, or HCPCS, code in the space below to get started.

Directions

1. Enter a CPT or HCPCS code in the space below.
2. Click Submit.
3. The tool will tell you if that service needs prior authorization.

Important notice

This tool provides general information for outpatient services performed by a participating provider.

The following services always require prior authorization:

• Elective inpatient services
• Urgent inpatient services

The results of this tool aren’t a guarantee of coverage or authorization. All results are subject to change in accordance with plan policies and procedures and the Provider Manual (PDF).

If you have questions about this tool or a service or to request a prior authorization, call Blue Cross Complete's Provider Inquiry at 1-888-312-5713.

Healthcare common procedure coding system medications 

A prior authorization for healthcare common procedure coding system medications is required before they are covered by Blue Cross Complete. Click the HCPCS PA List (PDF) for a list of codes that require prior authorization.

Prior authorization

Some medicines and benefits require prior authorization by Blue Cross Complete. Submit a prior authorization request using one of the following forms:

• Medication prior authorization online form
• Medication prior authorization request form (PDF)

You must submit a request for a prior authorization for your patient. You must also submit an override of a drug restriction. Request from pharmacies aren't accepted.  

Pharmacy billing

The electronic processing of retail pharmacy claims requires a NCPDP processor ID number, also known as a BIN, and a processor control number, or a PCN, for plan identification. Blue Cross Complete's D.0 Payer Sheet (PDF) contains our BIN (600428), PCN (06210000), member services number, field definitions and other helpful information for pharmacy claim billing and rebilling.

NaviNet

By logging on to the Blue Cross Complete payer-provider portal Navinet, you have the opportunity to:

• Receive news alerts in real time
• View Blue Cross Complete member information
• Submit authorization requests
• View gaps in care reports 
• Check the status of claims

Visit NaviNet Basics if you have not yet enrolled or would like more information.

Always check benefits through the Voice Response Unit (VRU) or My Insurance ManagerSM to determine if prior authorization is required.

Many of our plans require prior authorization for certain procedures and durable medical equipment. This process allows us to check ahead of time whether services meet criteria for coverage by a member’s health plan.

In many cases, approval is instant. When it’s not, we’ll review your request, taking into account:

• Our medical policies
• Recognized clinical guidelines
• Out-of-area patients (BlueCard®)
• The terms of the member’s benefit plan

Some requests may require additional documentation.

Prior authorization for medical services

When you request prior authorization from us, we want the process to be fast, easy and accurate. We offer these convenient options:

• Medical Forms Resource Center (MFRC) – This online tool makes it easy to submit prior authorization requests for certain services. The tool guides you through all of the forms you need so you can avoid follow-up calls for additional information. 
• My Insurance Manager – You also can submit prior authorization using the same online self-service provider tool you can use to check eligibility, manage claims and more. 
• Fax – If you would prefer to submit your request by fax, complete and follow the submission directions on this form:
  • Precertification Request Form

Prior authorization for behavioral health services

A few plans may continue to require prior authorization for behavioral health services to include applied behavioral analysis (ABA) therapy. To request prior authorization, contact Companion Benefits Alternatives (CBA) using one of the below options:

• Calling 800-868-1032
• Forms Resource Center – This online tool makes it easy for behavioral health clinicians to submit behavioral health prior authorization requests. The tool guides you through all of the forms you need so you can avoid follow-up calls for additional information.

CBA is a separate company that administers mental health and substance abuse benefits on behalf of BlueCross.