Anthem Prior Authorization Template 2026: AIM, EviCore, and IngenioRx Routing Guide

Why Anthem PA Goes to Three Different Organizations

Anthem's prior authorization process is split across multiple third-party utilization management vendors — and most billing teams don't know which portal to use until a submission bounces back.

Anthem Blue Cross Blue Shield (Elevance Health) has delegated specialty PA reviews to AIM Specialty Health, now operating under the Carelon brand, for the majority of high-cost imaging, musculoskeletal, and cardiology services. For oncology services in selected affiliates, EviCore (an Evernorth company) handles the clinical review. Pharmacy PA for specialty medications flows through IngenioRx, Anthem's pharmacy benefit manager, primarily via CoverMyMeds. Everything else goes directly to Anthem through Availity.

The problem is that Anthem's denial notices, remittance advice, and provider portals do not always make the routing source obvious. A billing team that defaults to Availity for every PA request will have imaging and spine submissions accepted, processed by the wrong team, and then either rerouted — adding days — or denied outright for improper submission channel.

For a complete overview of prior authorization denial reasons and appeal rights, see the prior authorization denial complete guide.

Anthem PA Service-Type Routing Matrix

Use this table as the starting point for every Anthem PA request. Always verify the routing for your specific affiliate and plan type on the Anthem provider portal at providers.anthem.com — delegated vendor relationships vary by state and can change between plan years.

Sources: Anthem affiliate provider manuals, AIM Specialty Health and EviCore vendor documentation, IngenioRx pharmacy benefit guides — current as of June 2026.

Submitting Prior Auth to AIM Specialty Health (Carelon)

For imaging, MSK, spine, and cardiology services, AIM Specialty Health is the correct submission destination — not Anthem. AIM operates under the Carelon Medical Benefits Management brand for most Anthem affiliate workflows.

How to submit a PA request through AIM:

1. Log into the AIM provider portal at aimspecialtyhealth.com (also accessible via providers.carelon.com)
2. Select your Anthem affiliate from the payer list
3. Complete the PA request form — include the ICD-10 diagnosis, CPT code, patient demographics, and ordering provider NPI
4. Upload supporting clinical documentation: office notes, prior treatment history, imaging results if a follow-up, and any specialist letters
5. Submit and capture the AIM Reference Number — this number is required if the PA is denied and you proceed to peer-to-peer review

What AIM reviewers evaluate:

AIM applies its Clinical Appropriateness Guidelines (CAGs), which are updated periodically. The MSK and spine guidelines were revised in Q2 2025 with more specific conservative treatment duration requirements before advanced imaging or surgical intervention. Before submitting, review the applicable CAG version for your service category at aimspecialtyhealth.com/guidelines. If the patient's documentation predates those criteria, note the specific guideline version in your submission.

Peer-to-peer review when AIM denies:

If AIM denies the PA, the peer-to-peer review window is 48 hours from the denial date. The peer-to-peer goes through AIM — not Anthem's utilization management team. Call AIM at 877-291-0366 and reference the AIM Reference Number from the denial notice. The ordering or treating physician must conduct the call. Billing staff cannot request or participate in the clinical P2P on the physician's behalf.

For a detailed walkthrough of the Anthem denial appeal process — including what happens when the AIM P2P does not reverse the denial — see the Anthem appeal letter template guide.

Submitting Prior Auth to EviCore for Oncology

EviCore Healthcare Solutions, now part of Evernorth Health Services, handles oncology PA for selected Anthem affiliates. This routing applies primarily to oncology treatment authorization — chemotherapy regimen approvals, high-cost oncology infusibles, and certain radiation oncology services — where EviCore's ClinicalLogic criteria govern the review.

Before submitting to EviCore, verify the routing:

Check the Anthem provider portal for your affiliate state under "Utilization Management" → "Prior Authorization Requirements." If EviCore is listed as the delegated reviewer for oncology, submit there. If AIM is listed instead — which is the case for some Anthem affiliates for radiation oncology — submit to AIM. Do not assume based on another affiliate's setup.

EviCore PA submission:

1. Access the EviCore provider portal at evicore.com/providers
2. Select Anthem as the payer and your affiliate state
3. Enter the patient's Anthem member ID, ICD-10 code, and the specific CPT code for the oncology service or drug
4. Attach clinical documentation: oncologist notes, pathology report, prior treatment history, and NCCN guideline reference where applicable
5. Submit and capture the EviCore case number

EviCore ClinicalLogic criteria:

EviCore applies its ClinicalLogic evidence framework — an internal criteria system that may be more or less restrictive than NCCN Guidelines depending on the service. If the clinical documentation aligns with NCCN guidance but EviCore's criteria are more restrictive, note the discrepancy in your submission. Denials that cite EviCore criteria more restrictive than current NCCN Category 1 recommendations can be challenged through EviCore's clinical reconsideration process.

For the peer-to-peer review process when EviCore denies, the window is 7 days from the denial date — longer than the AIM window but still tight. Contact EviCore's clinical review team through the case management portal at evicore.com/providers or call the number on the denial notice.

IngenioRx Pharmacy PA: CoverMyMeds vs. Availity

IngenioRx is Anthem's pharmacy benefit manager for most commercial and Medicare Advantage plans. Pharmacy PA for specialty medications, biologics, and non-preferred formulary drugs goes through IngenioRx — not through the standard Anthem Availity workflow.

CoverMyMeds (primary electronic PA channel):

CoverMyMeds is the preferred electronic PA submission path for IngenioRx pharmacy requests. Most specialty pharmacies and prescribing practices are already connected to CoverMyMeds. The workflow:

1. Open CoverMyMeds and search for Anthem/IngenioRx as the payer
2. Complete the ePA form with the drug name, NDC or HCPCS code, diagnosis, and clinical documentation
3. Attach step therapy failure documentation if applicable — IngenioRx requires documentation of failure on the required first-line agents for most biologic categories
4. Submit and capture the CoverMyMeds transaction ID

Availity Pharmacy (secondary channel):

For practices that do not use CoverMyMeds, Availity supports IngenioRx pharmacy PA submissions in some affiliate configurations. Log into Availity → Prior Auth → Pharmacy Benefits, and select the appropriate Anthem affiliate and IngenioRx as the PBM. Not all affiliates have this channel enabled — check your Anthem provider portal.

Formulary exceptions:

If the drug is a non-preferred brand where a preferred alternative exists, IngenioRx requires a formulary exception request in addition to PA. The exception must document why the preferred alternative is clinically inappropriate for this patient — intolerance, contraindication, or prior treatment failure with the preferred agent.

Standard Anthem PA via Availity

For services not delegated to AIM, EviCore, or IngenioRx, prior authorization goes directly to Anthem through Availity.

Availity PA submission:

1. Log into availity.com → Auth & Referrals → Prior Authorization
2. Select the appropriate Anthem affiliate from the payer dropdown
3. Enter member ID, ICD-10, CPT code, and requesting provider NPI
4. Attach clinical documentation — office notes, specialist referrals, and any prior treatment records supporting medical necessity
5. Submit and capture the Availity Tracking Number

NaviMed — Anthem's e-PA platform in select affiliates:

Some Anthem affiliates use NaviMed as their electronic prior authorization platform for specific workflows, particularly for services accessed through Anthem's clinical management programs. NaviMed is integrated with Availity in many configurations, but in some states it operates as a standalone portal linked from the Anthem provider portal. If Availity's PA submission channel does not display an Anthem result for your service type, check the Anthem provider portal for your state for NaviMed routing instructions.

Verifying PA requirements before submitting:

Anthem's PA requirements change by plan year. Use the Anthem PA lookup tool at providers.anthem.com before submitting to confirm whether a specific CPT code requires PA for a given affiliate, plan type, and member's contract. A PA submitted for a service that does not require authorization delays claim processing unnecessarily and creates an administrative paper trail without value.

Anthem Prior Authorization Request Template

Use this template for written PA submissions to Anthem, AIM, or EviCore. Adjust the recipient and reference numbers based on the correct routing vendor identified above.

[Practice Letterhead]
[Date]

[AIM Specialty Health / EviCore / Anthem Prior Authorization Department]
[Portal Submission or Fax Number from Anthem Provider Portal]

Re: Prior Authorization Request
Member Name:      [Patient Full Name]
Member ID:        [Anthem Member ID]
Date of Birth:    [DOB]
Group/Plan:       [Anthem Plan and Group Number]
Diagnosis:        [ICD-10-CM Code] — [Diagnosis Description]
Requested Service:[CPT Code] — [Procedure/Service Description]
Requested DOS:    [Date or Date Range]
Place of Service: [Inpatient / Outpatient / Office / Facility]
Requesting Provider: [Name, NPI, Practice, Phone, Fax]
Rendering Provider:  [If different from requesting]

─────────────────────────────────────────────────
CLINICAL SUMMARY
─────────────────────────────────────────────────

Patient is a [age]-year-old [sex] presenting with [diagnosis/condition].
Relevant history: [Duration of condition, prior diagnoses, comorbidities].
Current treatment: [Medications, PT, prior procedures as applicable].

─────────────────────────────────────────────────
MEDICAL NECESSITY JUSTIFICATION
─────────────────────────────────────────────────

The requested [service/medication] is medically necessary for this patient
because [specific clinical finding, objective measure, or symptom burden].

[For AIM submissions — address the applicable Clinical Appropriateness Guideline:]
Per AIM Clinical Appropriateness Guideline for [category], Section [X]:
  Criterion: [Exact criterion text]
  Patient meets criterion because: [Clinical documentation reference]

[For EviCore submissions — address ClinicalLogic criteria:]
Per EviCore ClinicalLogic [oncology service category]:
  Criterion: [Exact criterion text]
  Supporting evidence: [NCCN Category reference if applicable, clinical notes]

[For IngenioRx/pharmacy — document step therapy completion:]
Step therapy requirements:
  Step 1 — [Drug name]: Initiated [date], discontinued [date].
  Reason: [Intolerance / Inadequate response / Contraindication]
  Step 2 — [Drug name, if applicable]: Same format.
  Clinical basis for requested agent: [Specific medical necessity]

[For Anthem direct — document per applicable clinical criteria:]
Medical necessity documentation consistent with:
  [Anthem Medical Policy number, if available]
  [InterQual criteria, if applicable for level-of-care decisions]

─────────────────────────────────────────────────
CONSERVATIVE TREATMENT HISTORY (if applicable)
─────────────────────────────────────────────────

Prior treatment attempted:
  - [Treatment 1]: [Dates] — [Outcome]
  - [Treatment 2]: [Dates] — [Outcome]
  - [Treatment 3, if applicable]

Reason advanced service is now appropriate: [Clinical explanation]

─────────────────────────────────────────────────
SUPPORTING DOCUMENTATION ENCLOSED
─────────────────────────────────────────────────

  [ ] Office/visit notes: [dates]
  [ ] Diagnostic results (labs, imaging, pathology): [dates]
  [ ] Specialist letters or referral notes
  [ ] Prior treatment records
  [ ] Step therapy failure documentation (pharmacy PA)
  [ ] NCCN or clinical guideline excerpt (oncology)
  [ ] Prior authorization approval history (if concurrent/renewal)

─────────────────────────────────────────────────

This request is submitted on behalf of [Patient Name] for the above service.
Please direct questions or requests for additional clinical information to:

[Contact Name, Title]
[Practice Name]
[Phone] | [Fax]
[Email if accepted]
NPI: [Number]

Sincerely,
[Ordering Physician Name, Credentials]
[Practice Name]
[Date]

When Anthem PA Is Denied: Peer-to-Peer and Appeal Path

A PA denial from Anthem, AIM, or EviCore is not the end of the process. Each vendor has a distinct peer-to-peer window and formal appeal path.

For a complete Anthem appeal letter template and step-by-step written appeal guide, see the Anthem appeal letter template 2026. For peer-to-peer review strategy across all insurers, see the peer-to-peer review guide.

Anthem Affiliate PA Contact Reference

PA portals, phone numbers, and NaviMed availability vary across Anthem's 14-state footprint. This table covers key affiliates — always verify current details at providers.anthem.com/[your-state]-provider before submitting.

How Muni Appeals Supports Anthem PA Workflows

Anthem's split-vendor PA structure creates consistent submission errors for billing teams that handle multiple payers — the AIM/EviCore/IngenioRx/Availity routing decision is not obvious from the Anthem member ID or insurance card, and it changes by affiliate and by service category.

Muni Appeals helps practices navigate Anthem PA submissions and denials:

• Identifies the correct PA vendor for each service type and Anthem affiliate before submission
• Tracks AIM, EviCore, IngenioRx, and Anthem Direct submission deadlines and P2P windows in one place
• Builds PA request documentation organized around AIM Clinical Appropriateness Guidelines or EviCore ClinicalLogic criteria for the specific service
• Manages IngenioRx step therapy documentation and formulary exception requests for specialty pharmacy PA
• Routes formal written appeals to the correct Anthem affiliate appeals department when P2P review does not reverse the denial

Start 3 Free Appeals

Frequently Asked Questions

Does Anthem prior authorization always go through Availity?

No. Anthem has delegated specialty PA reviews to third-party vendors for many high-volume service categories. Imaging, MSK, spine, and cardiology PA go through AIM Specialty Health (Carelon). Oncology PA goes through EviCore in selected affiliates. Pharmacy PA for specialty medications routes through IngenioRx via CoverMyMeds. Only services not covered by those delegations are submitted directly through Availity's standard prior auth workflow.

How do I know if AIM Specialty Health is handling my Anthem PA request?

AIM-delegated service categories are listed in the Anthem provider manual for your affiliate state, accessible at providers.anthem.com. If a PA request is submitted to Anthem via Availity for an AIM-delegated service, Availity or Anthem should redirect you to AIM — but this rerouting is not immediate and adds days to the review. Check the PA requirement lookup tool first. If an AIM denial has been issued, look for "AIM Specialty Health" or "Carelon" in the denial header and an AIM Reference Number in the case details.

What is the Anthem PA deadline for standard commercial services?

Anthem commercial plan PA decision timelines vary by affiliate and service type. Standard non-urgent requests typically receive a decision within 5–14 business days. Urgent requests — where delay would seriously jeopardize the patient's health — are entitled to a determination within 72 hours under federal law (29 CFR § 2560.503-1 for ERISA plans, and ACA rules for fully-insured plans). Concurrent reviews for active inpatient admissions typically receive decisions within 1 business day.

What is IngenioRx and how does it handle pharmacy PA?

IngenioRx is Anthem's (Elevance Health's) pharmacy benefit manager for most Anthem commercial and Medicare Advantage plans. When a specialty medication, biologic, or non-preferred drug requires prior authorization, the request goes to IngenioRx — not to Anthem's medical PA team. Submit IngenioRx pharmacy PA through CoverMyMeds, which integrates with most specialty pharmacy and prescribing practice workflows. Formulary exceptions require separate documentation beyond the standard PA request.

Can I use CoverMyMeds for all Anthem PA submissions, or only pharmacy?

CoverMyMeds is the correct channel for IngenioRx (pharmacy benefit) PA requests. It is not used for medical service PA to AIM, EviCore, or Anthem's standard utilization management team. Medical service PA — imaging, procedures, inpatient, DME — goes through AIM's portal, EviCore's portal, or Availity depending on service type. CoverMyMeds and medical PA are entirely separate submission tracks at Anthem.

How long does EviCore take to decide an Anthem oncology PA?

EviCore standard reviews typically take 3–5 business days once a complete submission with supporting clinical documentation is received. Urgent submissions — where delay would cause clinical harm — must be processed within 72 hours. If submitting for an oncology PA that requires a ClinicalLogic criteria response, attach the relevant NCCN guideline excerpt with the initial submission. Denials citing criteria more restrictive than NCCN Category 1 recommendations can be challenged through EviCore's clinical reconsideration process, which has a 7-day peer-to-peer window from the denial date.

What happens if I submit an AIM-delegated PA through Availity by mistake?

Availity may accept the submission and route it to Anthem's internal UM team, which will then redirect it to AIM. This redirection process is not immediate — it typically adds 3–7 business days before AIM begins its review. The authorization clock does not start until AIM receives a complete submission. If the service has a clinical urgency component, the misdirection may cause the PA timeline to overlap with a scheduled procedure date. Submit directly to AIM for all imaging, MSK, spine, and cardiology requests.

Does the Anthem PA routing change for Medicare Advantage plans?

Yes. Anthem Medicare Advantage plans follow CMS prior authorization rules under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), which took effect January 1, 2026. For MA plans, AIM and EviCore continue to handle their respective service categories, but the decision timelines are governed by CMS requirements: standard MA PA decisions within 14 calendar days, expedited within 72 hours. If Anthem or AIM misses the CMS deadline on an MA PA, the denial is treated as a deemed approval in many clinical scenarios. Document the submission date and track the CMS deadline independently from the standard commercial timeline.

Ready to Submit Anthem PA Without the Routing Confusion?

The AIM/EviCore/IngenioRx/Availity split is Anthem's biggest billing workflow trap. A service that routes to the wrong vendor loses days — sometimes enough to interfere with a scheduled procedure or treatment start date.

Quick reference checklist before submitting any Anthem PA:

• Confirm service type and check Anthem provider portal for your affiliate's PA delegation list
• Imaging, MSK, spine, cardiology → AIM at aimspecialtyhealth.com (877-291-0366)
• Oncology (selected affiliates) → EviCore at evicore.com/providers
• Specialty medication, biologic, non-preferred drug → IngenioRx via CoverMyMeds
• All other services → Anthem direct via Availity → Prior Auth
• Capture and record the submission reference number from whichever vendor received it
• Track the clinical urgency threshold — if urgent, state it and request 72-hour review at submission

Start 3 Free Appeals

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This guide reflects 2026 Anthem Blue Cross Blue Shield prior authorization procedures across all 14 Anthem affiliates. Delegated vendor relationships, PA requirements by service category, and portal routing are subject to change by plan year and affiliate. Always verify current PA requirements at providers.anthem.com for your specific affiliate. This guide does not constitute legal or clinical advice.