Prior authorization requirements
Determine how to submit authorization requests and what services require prior authorization.
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.
Don't have an Availity account?
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.
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.