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. BCBSGa’s medical policies are available on our provider website at bcbsga.com/provider.

 

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 bcbsga.com/provider website.

 

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.–5:00 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.–7:00 p.m.
  • 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

800 662-9023, 800 722-6614,

855-343-4851 or
855-343-4852

 

Transplant:
800-824-0581

 

Behavioral Health:
800-292-2879

 

Autism: 844-269-0538

 

University System of Georgia (USG): 
800-233-5765

 

Behavioral Health:
844-269-0535

 

State Health Benefit (SHBP) Behavioral Health: 855-679-5725

 





FEP:
Phone 800-860-2156

FAX 800-732-8318 (UM)

FAX 877-606-3807 (ABD)

877-771-9165

 







Behavioral Health:
800-292-2879

 



University System of Georgia (USG):

877-771-9165

 

Behavioral Health:
844-269-0535

 

State Health Benefit (SHBP) Behavioral Health: 855-679-5725

 

State Health Benefit (SHBP) Medical:
855-668-6442

 

FEP:
Phone 800-860-2156

 

800-662-9023, 800-722-6614, 855-343-4851 or
855-343-4852

 





Behavioral Health:
800-292-2879

 



University System of Georgia (USG):
800-233-5765

 

Behavioral Health:
844-269-0535

 

State Health Benefit (SHBP) Behavioral Health: 855-679-5725

 

State Health Benefit (SHBP) Medical:
855-668-6442

 

FEP:
Phone 800-860-2156

FAX 800-732-8318 (UM)

FAX 877-606-3807 (ABD)


TDD/TTY

711

Or

TTY: 800-255-0056

Voice: 800-255-0135


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 BCBSGa Provider Newsletter