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Referrals and Prior Approvals

Some Anthem Medicaid services and benefits need prior approval. This means your provider must ask us to approve the services he or she wants you to have. Look at the chart below to see which services might need approval or a referral from your PCP.

Referrals

Wait! You need a referral first!


Your PCP needs to give you a referral to see these kinds of doctors for care.

  • Specialist care

Good to go! You don’t need a referral.

You don’t need a referral from your PCP to get these types of services.

  • Preventive and routine services from an OB/GYN in your plan
  • Primary vision, dental and oral surgery services, as well as exams by orthodontists and prosthodontists
  • Special health care needs that need special treatment or should be checked regularly
  • EPSDT services
  • Routine shots
  • Screening or testing for sexually transmitted diseases, including HIV
  • Family planning
  • Emergency care
  • Behavioral health services
  • Pharmacy services

Prior approvals

Wait! You need prior approval first.

This means your provider has to ask us to approve these services before you can get them.

  • MRA
  • MRI
  • CAT scans
  • Nuclear cardiac
  • ECHO
  • All inpatient services
  • All out-of-network services
  • Multiple doses of medicines
  • Brand-name drugs if there is an appropriate generic version
  • A greater quantity of medicine than our standard 30-day supply

Good to go! You don’t need approval.
We don’t need to OK these services before you get them.

  • Emergency care
  • Visits to urgent care centers
  • Family planning services

Our Utilization Review team looks at approval requests. The team decides if:

  • The service is medically needed
  • The service is one that is included in your Anthem Medicaid benefits

What should you do if Anthem Medicaid won’t approve care you think you need? You or your provider can ask us to take another look. We’ll let you and your provider know when we get your request. You can ask us to take another look at services that:

  • Are not approved
  • Have been limited in the amount or length of time from what was requested

How we make decisions on care and services

Sometimes, we need to make decisions about how we pay for care and services. This is called Utilization Management (UM).

Our UM program:

  • Looks at what, when and how much of our services are medically needed.
  • Always strives for the best possible health outcomes for our members.

Our UM program does not:

  • Tell doctors to withhold or give you fewer services.
  • Stop certain people from getting services.
  • Reward doctors for limiting or denying care.

Do you have questions about an approval or a denial you got?

Call Member Services at 1-855-690-7784 (TTY 711). Our Utilization Review team or your case/care manager can help answer your questions.

Your opinion matters!

Every year, we survey our members about the benefits we offer. If you get a survey by mail, email or phone, please complete it. Help us make your plan better.