Anthem denied prior authorization? Here’s what to do

Why Anthem denied prior authorization

• The request lacked a letter of medical necessity or clinical notes.
• Anthem considers the service experimental or not medically necessary.
• A formulary or step-therapy rule required trying another option first.
• The request used the wrong code or was missing supporting records.

Calling Anthem: what to expect

Anthem’s line is 1-833-848-8729; member services is typically Mon–Fri, roughly 8am–8pm local time; the hours differ by state plan.

To reach a person: enter your member ID from your card, then press the option for claims and benefits, or say "claim status", then say "agent" or "representative" to leave the automated menu. Menus change — if yours does not match, say "representative" at any prompt.

Self-service runs through Sydney Health (app) / anthem.com (https://www.anthem.com); the written route is the Anthem Member Grievance and Appeal form (state-specific; downloadable in Sydney Health or on your state’s anthem.com pages); and you may see these names on your paperwork: Anthem Sydney Health, Anthem BlueCard.

Step by step: what to do

1. Call Anthem at 1-833-848-8729 (enter your member ID from your card, then press the option for claims and benefits, or say "claim status", then say "agent" or "representative" to leave the automated menu) and get the precise reason for the prior-auth denial.
2. Ask your prescriber to submit a letter of medical necessity with clinical notes.
3. Request a peer-to-peer review between your doctor and the Anthem medical director.
4. File a written appeal through the appeal address on your denial letter or the Anthem member portal before the 180 days from the date of the denial deadline.
5. If your health is at risk, request an expedited (urgent) appeal.

Common mistakes to avoid

• Waiting on the doctor’s office instead of driving the appeal yourself.
• Skipping the peer-to-peer review, which often resolves the denial fastest.
• Not requesting an expedited appeal when the delay could harm your health.

What to say when you call Anthem

• I’m appealing a prior-authorization denial and want to schedule a peer-to-peer review.
• Please tell me exactly what clinical documentation is missing.
• If this is time-sensitive, I’m requesting an expedited appeal.

Anthem-specific things to know

• Anthem prior auths are handled through Availity for providers and show in Sydney Health for you — check status there before you call.
• For imaging and some procedures, Anthem uses a review vendor (Carelon); the peer-to-peer may be with that vendor rather than Anthem directly.
• Anthem is a licensee of the Blue Cross Blue Shield Association in about 14 states — the exact rules, forms and phone hours depend on which state issued your plan.
• Care received out of state runs through BlueCard, so a claim may be processed by the local Blue plan and then sent back to Anthem — denials can bounce between them.
• Sydney Health shows claim status, EOBs and prior-auth status; screenshots from it are useful appeal exhibits.
• Anthem uses different phone numbers for Medicaid, Medicare Advantage and commercial plans; the card number is the one to use.

Know your rights

You have the right to a written explanation of any denial, to a full copy of your plan documents, and to appeal — first internally, then through an independent external review.

Regulator: your state Department of Insurance (and the federal No Surprises Act). If the internal appeal fails, request an external review and file a complaint with your state Department of Insurance.

If Anthem will not move, the escalation paths that carry weight:

• Ask for a second-level appeal, and in most Anthem states, an expedited grievance if care is time-sensitive.
• Request independent external review through your state Department of Insurance or its external-review program.
• Escalate to your state Department of Insurance — Anthem is a state-licensed Blue plan, so the state regulator carries weight.

Frequently asked questions

Related guides

• Cigna: prior authorization denial
• Aetna: prior authorization denial
• UnitedHealthcare: prior authorization denial
• Anthem: denied claim
• Anthem: surprise medical bill
• Anthem: out-of-network coverage