Medical Policies and Clinical Utilization Management Guidelines update
The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.
- Effective November 1, 2018, AIM Specialty Health®
(AIM) Musculoskeletal Level of Care Guidelines, Sleep Study Guidelines and Radiology Guidelines will be used for clinical reviews.
- When requesting services for a patient (including medical procedures and medications), the Precertification Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.
Please share this notice with other members of your practice and office staff.
To search for specific policies or guidelines, visit https://www.anthem.com/ca/medicalpolicies/search.html.
Please open the attachment to view the list of new and revised Medical Policies and Clinical Utilization Management Guidelines.
January 2019 Anthem Blue Cross Provider Newsletter - California