Our utilization management (UM) decisions are based on written criteria, the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor, do we 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 under-utilization.  Anthem’s medical policies are available on Anthem’s website at anthem.com.

 

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below.  UM criteria are also available on the web. Just select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at anthem.com.

 

We work with providers to answer questions about the utilization management process and the authorization of care.  Here’s how the process works:

  • Call us toll free from 8:30 a.m. - 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area.  Federal Employee Program hours are 8:00 a.m. - 7 p.m. Eastern.
  • If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day.  Calls received after midnight will be returned the same business day. 
  • Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

 

The following phone lines are for physicians and their staffs.  Members should call the customer service number on their health plan ID card.

 

To discuss

UM Process

and Authorizations

To Discuss Peer-to-Peer

UM Denials w/Physicians 

To Request UM Criteria

TTY/TDD

 

Phone 800-832-7850

Fax 800-763-3142

 

Autism

844-269-0538

 

For members with a pre-existing condition and/or active lifetime benefit exclusion, fax to: 

800-947-4074 

 

FEP

Phone 800-860-2156

Fax 800 732-8318 (UM)

Fax 877 606-3807(ABD)

Local:  303-764-7227

Toll-free: 866-287-1654

 

No fax number to request Peer-to-Peers.

 

FEP

Phone 800-860-2156 

800-797-7758

 

No fax number. Providers leave message with: provider name, provider phone number, member’s name, member ID, and reference number.

 

FEP

Phone 800-860-2156

FAX 800 732-8318 (UM)

FAX 877 606-3807(ABD)

711 or  TTY / Voice

800-659-2656(T)/ 

800-659-3656(V)

 

For language assistance, members can simply call the Customer Service phone number on the back of their ID card and a representative will be able to assist them.

 

Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.  They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.



















































Featured In:
December 2018 Anthem Provider Newsletter - CO