Important information about utilization management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as members’ coverage according to their health plan. We do not:

• Reward providers or other individuals for issuing denials of coverage, service, or care. 
• Make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. 
• Offer financial incentives for UM decision makers to encourage decisions resulting in underutilization. 

Our medical policies and UM criteria are available online via our provider website at

anthem.com/provider/policies/clinical-guidelines/search.

You can request a free copy of our UM criteria from the Medical Management department or discuss a UM denial decision with a physician reviewer by calling Provider Services (see below for the toll-free numbers).

We are staffed with clinicians who coordinate our members’ care and are available 24/7 to accept precertification requests. Secure voicemail is available before and after business hours. A clinician will return your call the next business day. Our staff will identify themselves by name and title, and if relevant, organization name, when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

• Submitting online at: 
  • Availity Essentials:* Availity.com.
• Calling Provider Services at:
  • Hoosier Healthwise: 866-408-6132.
  • Healthy Indiana Plan: 844-533-1995.
  • Hoosier Care Connect: 844-284-1798.
•  Faxing us at:
  • Inpatient medical: 866-406-2803.
  • Outpatient medical: 866-406-2803.
  • Pharmacy (retail): 844-864-7860.
    • Medical injectable: 888-209-7838.
  • Behavioral health inpatient: 844-452-8074.
  • Behavioral health outpatient: 844-456-2698.

If you have questions about utilization decisions or the UM process, call Provider Services at one of the numbers listed above, Monday through Friday, from 8 a.m. to 8 p.m.