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 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 and UM criteria are online at https://mediproviders.anthem.com/ky/pages/other-resources.aspx, or you can request a free copy of our UM criteria from our Medical Management department by calling 855-661-2027. Within seven calendar days of the date of denial, providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at 855-661-2027.

 

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secured voicemail is available during off-business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and being with Anthem Blue Cross and Blue Shield Medicaid when initiating or returning calls regarding UM issues.

 

You can submit precertification requests by:

• Calling us at 855-661-2028.
• Faxing to 800-964-3627.
• Submitting online via Availity Essentials* at www.availity.com.

 

Have questions about utilization decisions or the UM process?

Call our Clinical team at 855-661-2028, Monday through Friday, from 7 a.m. to 7 p.m.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Medicaid.
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