Prior authorization requirements

Determine how to submit authorization requests and what services require prior authorization.

Attention Kansas Providers: Availity tools and services will be available for use beginning December 15th, 2024. Please contact our Provider Services team for more information.

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Submit prior authorization requests

Healthy Blue accepts prior authorization requests via Availity or, if you prefer paper submissions, via phone or fax. You may also use Availity’s Maternity Module to report a member’s pregnancy. Please visit our Forms page for all prior authorization forms.

 

To request or check the status of a prior authorization request or decision for a particular plan member, log in to Availity and select Patient Registration and select Authorizations & Referrals.

 

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Behavioral health

Please submit all prior authorization requests through our preferred method via Availity. However, if you prefer to paper fax, please submit correct forms to: 

 

Behavioral health inpatient fax:  1-866-852-8976

 

Behavioral health outpatient fax:  1-866-852-8978

 

 

Behavioral health revenue codes

Services billed with the following revenue codes always require prior authorization:

0240-0249 — all-inclusive ancillary psychiatric 

0901, 0905-0907, 0913, 0917 — behavioral health treatment services 

0944-0945 — other therapeutic services 

0961 — psychiatric professional fees

Pharmacy

Healthy Blue follows the Kansas Department of Health and Environment (KDHE) Preferred Drug List (PDL), formulary, and Prior Authorization (PA) criteria. For information on the Kansas Medicaid Pharmaceutical Program, please visit the Kansas Medicaid (FFS & MCO) Pharmaceutical Program. 

 

Kansas Department of Health and Environment (KDHE) Preferred Drug List (PDL) 

 

Formulary Searchable Tool (Pharmacy Benefit) (Coming soon)

 

KDHE Clinical PA Criteria and Forms 

 

Kansas Medicaid (FFS & MCO) Pharmaceutical Program 

 

KDHE Provider Interactive Tools 

 

 

Note: When using the KDHE provider interactive tools, use the Search by NDC function to determine pharmacy benefit.  Use the Search by Procedure function to locate physician-administered drugs. 

 

 

 

Pharmacy prior authorization

To submit pharmacy prior authorization requests: 

 

Call 1-833-838-2595

 

Fax:  1-877-941-9901

 

e-PA: CoverMyMeds 

 

 

 

Physician-administered drugs prior authorization

To submit physician-administered drug prior authorization requests: 

 

Call:  1-833-838-2595

 

Fax:  1-877-941-9841

 

e-PA: CoverMyMeds 

 

 

 

KDHE Preferred Drug List (PDL)

The PDL does not contain a complete list of covered drugs; rather, it lists the preferred drugs within the most prescribed therapeutic categories. The PDL applies to drugs billed on the medical benefit and the pharmacy benefit. Generic drugs and interchangeable biologic products are required when available on the market, for both preferred and non-preferred agents, unless a Brand Medical Necessity prior authorization request is approved. Members needing non-preferred drugs must meet the non-preferred prior authorization criteria. Additionally, some PDL drugs also have clinical prior authorization requirements. 

 

KDHE Preferred Drug List 

 

 

 

Pharmacy revenue codes

Services billed with the following revenue codes always require prior authorization: 

0632 — pharmacy multiple sources 

Elective services

Elective services provided by or arranged at nonparticipating facilities always require prior authorization.

Need more assistance with authorization?

Check out our Prior authorization lookup tool to determine prior authorization requirements or contact Provider Services for assistance.

Interested in becoming a provider in the Healthy Blue network?

We look forward to working with you to provide quality service for our members.

 

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