CommercialDecember 1, 2024
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 under-utilization. Anthem medical policies are available at Anthem.com.
You can also request a free copy of our UM criteria from our medical management department, and each treating provider directly involved in the member’s care may discuss a UM denial decision with a physician reviewer by calling us at the toll-free number listed on the UM denial letter, if they haven’t already done so, and before all applicable appeals are completed. UM criteria are also available on the web. Go to Anthem.com and select For Providers > Provider Resources > Policies, Guidelines and Manuals > Select your state > View Medical Policies & Clinical UM Guidelines.
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. to 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program (FEP) hours are 8 a.m. to 7 p.m. ET.
- 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 following phone lines are for physicians and their staff. Members should call the customer service number on their health plan ID card.
To discuss UM process and authorizations | To discuss | To request UM criteria | TDD/TTY
| Business hours |
800-992-5498 Transplant: Autism: FEP: | 888-870-9342 National: Adaptive Behavioral Treatment: FEP:
| 800-992-5498 Behavioral Health: FEP: | 711 Voice: | Call us toll-free from 8:30 a.m. to 5 p.m. Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program hours are 8 a.m. to 7 p.m. ET.
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For language assistance, members can call the customer service phone number on the back of their ID card and a representative will be able to assist them.
Our utilization management associates identify themselves to all callers by first name, title, and company name when making or returning calls. They can inform you about specific utilization management requirements and operational review procedures and discuss utilization management decisions with you.
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MOBCBS-CM-072612-24
PUBLICATIONS: December 2024 Provider Newsletter
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