Important information about utilization management

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.