Important information about utilization management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed as well as the member’s coverage according to their health plan. We do not reward care providers or other individuals for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. Our Medical Policies are available on our provider website at providers.anthem.com/ca > Resources > Medical Policies and Clinical UM Guidelines.

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 providers.anthem.com/ca > Resources > Medical Policies and Clinical UM Guidelines.

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

You can submit precertification requests 24/7 by:

• Calling: 888-831-2246, option 3 (includes both inside and outside L.A. County).
• Faxing a Pre-Service Review form to 800-754-4708 (includes both inside and outside L.A. County).

Have questions about utilization management?

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’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities.