Essential UM guidelines for timely service preapproval and reimbursement

As a healthcare care provider, staying informed about the utilization management (UM) process is crucial for optimizing patient care and streamlining administrative functions and claims submissions. This guide details submission methods and contact information, ensuring you have the resources to facilitate approvals efficiently. Review our website's Provider Manuals, Policies and Guidelines at Provider Manuals, Policies & Guidelines | California Provider — Anthem Blue Cross.

How UM decisions are made

UM decisions are based on the medical necessity of requested services and the member’s coverage under their benefit plan. Care providers or others are not compensated, rewarded, or incentivized to restrict coverage for medically necessary healthcare benefits. Our Medical Policies are available on our provider website at Provider Manuals, Policies & Guidelines | California Provider — Anthem Blue Cross.

You can request a free copy of our UM criteria from our Medical Management department. Care providers can discuss a UM denial decision with a physician reviewer by calling us toll free at 888‑831‑2246, option 4. To access UM criteria online, go to Provider Manuals, Policies & Guidelines | California Provider - Anthem Blue Cross.

How to submit a preapproval request

You can submit preapproval requests 24/7 by:

• Visiting Availity Essentials at https://Availity.com.
• Faxing a Pre-Service Review form to 800‑754‑4708 (includes inside and outside L.A. County).
• Calling: 888‑831‑2246, option 3 (includes inside and outside L.A. County).

Have questions about the UM process?

Call one of our Medi‑Cal Customer Care Centers Monday through Friday, from 7 a.m. to 7 p.m., at 800‑407‑4627 (TTY 711) outside L.A. County or 888‑285‑7801 (TTY 711) inside L.A. County.

We are staffed with clinical professionals who work with you to coordinate our members’ care. When initiating or returning calls regarding UM issues, our staff will identify themselves by name, title, and organization name.

What if I need assistance?

Availity Essentials Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. To access Availity Essentials, go to https://Availity.com and select the appropriate payer space tile from the drop‑down. Then, select Chat with Payer and complete the form to start your chat. For additional support, visit the Contact Us section at the bottom of our care provider website for the appropriate contact.