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. 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 underutilization.

You can request a free copy of our UM criteria from our Medical Management department. 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 the numbers listed below.

 

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 with Anthem Blue Cross and Blue Shield Medicaid when initiating or returning calls regarding UM issues.

 

Our medical policies and UM criteria can be found online at https://mediproviders.anthem.com/ky/pages/other-resources.aspx.

 

You can submit precertification requests by:

• Calling us at 1-855-661-2028.
• Faxing to 1-800-964-3637.
• Submitting online at https://www.availity.com

 

Have questions about utilization decisions or the UM process?

Call our Clinical team at 1-855-661-2028 Monday through Friday from 7 a.m. to 7 p.m.