Virginia Medicaid Service Authorization Metrics for Medical Items and Services (Excluding Drugs)

Prior Authorization Metrics for medical items and services (excluding drugs)

To meet the CMS Interoperability and Prior Authorization final rule, the Anthem HealthKeepers Plus plan must post a yearly summary on our website that shows how we handle prior approval requests for medical care. This includes a list of all medical services and supplies (not including drugs) that need approval before use, along with data showing how many requests were approved or denied in the past year. Sharing this information helps keep things clear and honest.

For questions on the data below, members and providers can contact HealthKeepers, Inc. at 800-901-0020 (TTY 711), Monday through Friday from 8:30 a.m. to 5:00 p.m.

These are the medical supplies and services that need approval first (not including drugs):

Search Prior Authorization Service List 
 

 Access Prior Authorization Service List (PDF)

Before January 1, 2026, Medicaid Managed Care Plans must give prior approval decisions within these time limits:

• 72 hours for expedited (urgent) requests
• 14 calendar days for standard (non-urgent) requests

Starting January 1, 2026, new federal rules from CMS will require Medicaid Managed Care Plans to give prior approval decisions within these time limits:

• 72 hours for expedited (urgent) requests
• 7 calendar days for standard (non-urgent) requests

Annual Reporting Metrics

Reporting Year: 2025

Data reported are current decisions as of 12/31 of the reporting calendar year.

*An overturn on appeal does not necessarily indicate an inappropriate initial prior authorization decision because the overturn may be a result of additional information received or changes in the member’s clinical presentation.