Anthem Blue Cross and Blue Shield (Anthem)’s 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 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 go to anthem.com, then scroll down and select Tools for Providers > Find Resources for Your State > select your State > Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements.

 

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. EST Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8:00 a.m. – 7:00 p.m. EST.
  • 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 grid below lists the phone lines for physicians and their staffs. Members should call the customer service number on their health plan ID card.

 

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.

 

 

To discuss UM Process and Authorizations

To Discuss Peer-to-Peer UM Denials w/Physicians

To Request UM Criteria

Indiana

800-345-4348,

877-814-4803

Behavioral Health: 866-582-2293

Transplant: 800-824-0581

Autism: 844-269-0538

888 870 9342

 

877-814-4803

 

Kentucky

800-568-0075

KEHP: 844-402-5347

Behavioral Health: 866-582-2293

Transplant: 800-824-0581

Autism: 844-269-0538

877-814-4803

 

877-814-4803

 

Missouri

800-992-5498

866-398-1922

Behavioral Health: 866-302-1015

Transplant: 800-824-0581

Autism: 844-269-0538

800-992-5498

866-398-1922

 

CDHP/Lumenos:

866-398-1922

800-992-5498,

866-398-1922

 

Ohio

800-752-1182

Behavioral Health: 866-582-2293

Transplant: 800-824-0581

Autism: 844-269-0538

877-814-4803

 

877-814-4803

 

Wisconsin

800-242-1527, 800-472-6909,

800-472-8909, 866-643-7087

Transplant: 800-824-0581

Autism: 844-269-0538

800-242-1527,

800-472-6909,

866-643-7087

 

800-242-1527,

800-472-6909

 

FEP/ National

FEP: 800-860-2156

Fax: 800 732-8318 (UM),

Fax: 877 606-3807 (ABD)

FEP: 800-860-2156

 

National: 800-821-1453;

866-776-4793

FEP: 800-860-2156

Fax: 800 732-8318 (UM)

Fax: 877 606-3807 (ABD)

 

TTY Information:

 

 

 

TTY

Voice

Indiana

711 or

1-800-743-3333 (V/T)

1-800-743-3333 (V/T)

Kentucky

711 or

1-800-648-6056 (T/ASCII/HCO)

1-800-648-6057 (V)

Missouri

711 or

1-800-735-2966 (TTY/ASCII)

1-866-735-2460 (V)

Ohio

711 or

1-800-750-0750 (TTY/Voice/HCO)

1-800-750-0750 (TTY/Voice/HCO)

Wisconsin

711 or

1-800-947-3529 (TTY/HCO)

1-800-947-6644 (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.

 



Featured In:
December 2019 Anthem Provider News - Indiana