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.

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.

Managing any illness can be challenging. Knowing who to contact, what test results mean, and how to access needed resources is important but can be overwhelming.

We are available to help with our case management program. Our case managers are part of an interdisciplinary team of clinicians and professionals who support members, families, primary care physicians, behavioral health practitioners, and caregivers. The case management process utilizes the experience and expertise of the care coordination team, whose goal is to educate and empower our members to increase their self-management skills, understand their illness, and learn about care choices to access quality, efficient healthcare.

Members or caregivers can refer themselves or family members for physical health services by calling the number below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals. This voluntary program is private and offered at no cost to our members. They can opt out anytime if they change their mind about participating in the program.

For behavioral health or substance use disorder services, members can contact their health plan to verify benefits and access at Anthem.com or if they are Federal Employee Program (FEP) members, https://www.fepblue.org/ to search for and access behavioral health providers. To ensure privacy, having the member or member’s family contact our department directly is best.

How do you contact us?

The member can contact customer service for assistance for commercial and exchange members.

For FEP members, physical and behavioral health practitioners can refer to our behavioral health case management by calling 800‑711-2225, option 3, with member consent.

We are committed to helping patients more easily access the care they need.

We are dedicated to ensuring compliance with NCQA accessibility standards by providing members with phone access to their PCPs beyond regular business hours. The annual after‑hours access study assesses adequate phone messaging for our members with perceived emergencies or urgent situations after office hours. Most of our plans measured still fall short of the after‑hours access expectations that patients have phone access to their practitioners 24 hours a day, 7 days a week, 365 days a year.

The current after‑hours messaging requirement is: When a patient calls after hours, a live person directs them to the practitioner or the on‑call practitioner, or a recording or live person directs the patient to an urgent care center, 911, or the ER.

If a patient reaches a practitioner’s voicemail, compliant messaging is imperative to assist the patient in gaining access to appropriate care.

We continue to work towards identifying simplified ways to access care.

Coordination of care among providers is vital to good treatment planning and ensures appropriate diagnosis, treatment, and referral. We want to take this opportunity to stress the importance of communicating with your patients’ other healthcare practitioners, including PCPs/PMPs, medical specialists, and behavioral health practitioners.

Coordination of care is essential for patients who use general medical services extensively and those referred to a behavioral health specialist by another healthcare practitioner. We urge all our practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other healthcare practitioners when treatment begins.

We expect all healthcare practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.
2. Obtain a signed release from the patient and file a copy in the medical record.
3. Document in the medical record if the patient refuses to sign a release.
4. Document in the medical record if you request a consultation.
5. If you make a referral, transmit the necessary information; if you furnish a referral, report appropriate information to the referring practitioner.
6. Document evidence of clinical feedback (for example, a consultation report) that includes, but is not limited to:
• Diagnosis
• Treatment plan
• Referrals
• Psychopharmacological medication (as applicable)

To facilitate coordination of care, we have several tools available at https://www.Anthem.com/provider/forms/ for behavioral health and other medical practitioners, including:

• Coordination of Care Form
• Coordination of Care Letter Template — Behavioral Health
• Coordination of Care Letter Template — Medical
• Resources for provider collaboration and integrated care, including Practice Guidelines, assessment tools, suicide awareness, and multicultural education and guidance

The following behavioral health forms, brochures, and screening tools for substance use disorder and attention‑deficit/hyperactivity disorder (ADHD) are also available at https://www.Anthem.com/provider/forms/:

• Alcohol use assessment brochure
• Antidepressant medication management
• Edinburgh Postnatal Depression Scale
• Opioid use assessment brochure
• Substance Brief Intervention/Referral Tool (SBIRT)
• Vanderbilt ADHD Diagnostic Parent Rating Scale

We are committed to finding solutions that help our care provider partners offer quality services to our members.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health, and preventive health guidelines, which are available to care providers on our website. The guidelines, which are used for our quality programs, are based on reasonable, medical evidence and are reviewed for content accuracy, current primary sources, the newest technological advances, and recent medical research.

All guidelines are reviewed annually and updated as needed. The current guidelines are available on our website at Anthem.com under For Providers. Select Policies, Guidelines & Manuals under Provider Resources. Select your state, then scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

Annual benefit changes for Medicare Advantage plan members under Anthem Blue Cross and Blue Shield will be effective January 1, 2025.

Refer to attachment to view full details.

Skilled nursing facilities (SNF) compensated based on the prospective payment system for outpatient Medicare Advantage claims may see a change in vaccine serum reimbursement. Beginning March 1, 2025, Part B‑covered vaccines will be reimbursed based on the CMS‑published vaccine serum rates.

We are committed to helping patients more easily access the care they need.

The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners, and members in our system, Anthem has adopted a Members’ Rights and Responsibilities statement.

The statement can be found on our website on the FAQ page. To access it, go to Anthem.com and select For Providers. From there, select Policies, Guidelines & Manuals under Provider Resources. Select your state and scroll down to Member Rights and Responsibilities under More Resources. Select the Read about member rights link. Then, under Laws and Rights that Protect You, select the question that says What are my rights as a member?

Practitioners may access the Federal Employee Plan (FEP) member portal at fepblue.org/memberrights to view the FEP Member Rights and Responsibilities statement.

Our Sleep Apnea Program offers clinical and behavioral health support.

Creating the best health outcomes for your patients — our consumers — takes our combined efforts. That’s why we’re dedicated to partnering with care providers to focus on holistic, integrated care. This includes connecting behavioral and physical health, such as through our Sleep Apnea Program.

Untreated obstructive sleep apnea is related to physical conditions such as high blood pressure and behavioral health conditions such as anxiety and depression.^1,2 Through our Sleep Apnea Program, consumers receive support from our case managers and lifestyle coaches who collaborate with their specialty care providers to help better manage their overall health. The program helps address the multifaceted impact obstructive sleep apnea can have on consumers and their families.

Program eligibility

It’s available to over 15,000 of our consumers across all lines of business, ages  60 to 75.³ Eligibility is determined by diagnosis of both obstructive sleep apnea and a behavioral health condition, alongside at least two of the following:

• Hyperlipidemia
• Hypertension
• Obesity
• Substance use disorder
• Type 1 diabetes
• Type 2 diabetes

No patient referral is required; those who qualify are automatically identified through claims information and enrolled in the program. Be sure to talk with your patients who may be eligible and encourage them to participate.

The Sleep Apnea Program is one example of how we’re working to transform healthcare with the goal of lowering costs and improving well-being.

Through our shared health vision, we can affect real change.

If you have any questions, contact your Anthem provider relationship management representative.

The Inflation Reduction Act and its impact on Part D Rx HCC model for 2025

On August 16, 2023, President Biden signed the Inflation Reduction Act (IRA) into law. This act brought about crucial reforms in the U.S. healthcare system, specifically impacting Medicare Advantage and Medicare Part D programs.

Starting January 1, 2025, the Part D Rx Hierarchical Condition Categories (HCC) risk adjustment (RA) model will undergo significant updates, reflecting the redesigned Part D benefits mandated by the IRA. This Medicare model helps categorize beneficiaries based on their overall health status and expected prescription drug costs. It will use diagnosis and drug utilization data to help predict healthcare costs associated with managing chronic conditions such as hypertension, COPD, and depression.

As part of the Part D Rx HCC model, it is essential for clinicians to thoroughly assess their patients’ active chronic conditions for presence or absence during each encounter and at least once each year. By maintaining comprehensive, accurate, and complete documentation during patient visits and coding to the highest level of specificity, providers can significantly enhance:

• Submission of accurate and complete clinical documentation, coding, and data,
• Appropriate resources to support effective management of costs,
• Quality of patient care, and
• Adherence to compliance regulations.

Thank you for your attention to these important updates. As clinicians, your commitment to accurate and complete documentation and compliant coding practices is essential. Together, we can navigate these changes and support the ongoing delivery of quality patient care.

If you have any RA Part D Rx HCC questions, please contact your Provider Success point of contact to coordinate efforts with the Enterprise Risk Adjustment team. For more detailed Part D model information, please visit the CMS website by clicking this link.

Summary: On August 16, 2024, the Pharmacy and Therapeutic (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. For questions or additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other members of your practice and office staff.

Please note:

• The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.
• This notice is meant to inform the provider of new or revised criteria that has been adopted by Anthem only. It does not include details regarding any authorization requirements. Authorization rules are communicated via a separate notice.

At a glance:

• Carelon Medical Benefits Management will expand programs to include cardiovascular, musculoskeletal, and surgical reviews beginning March 1, 2025.
• Additional outpatient UM will include transportation, fertility, and various other therapeutic and monitoring services.
• Providers must obtain online pre‑service reviews for certain procedures starting February 24, 2025.

As a reminder, effective March 1, 2025, Carelon Medical Benefits Management will expand multiple programs to perform medical necessity reviews for additional procedures for our members. Carelon Medical Benefits Management works to improve healthcare quality and manage costs for today’s most complex and prevalent tests and treatments, helping promote appropriate, safe, and affordable care.

The continued migration will expand clinical appropriateness reviews for procedures related to the following existing Carelon Medical Benefits Management programs: cardiovascular, musculoskeletal, and surgical. In addition, some codes will migrate into a new Carelon Medical Benefits Management solution — additional outpatient UM that will include some transportation (including ambulance) and fertility procedures, as set forth below. Transportation may include emergency post‑service reviews.

Our Clinical UM Guidelines and Medical Policies (also known as coverage guidelines in Virginia) for medical necessity review are listed in the table below. Carelon Medical Benefits Management will begin accepting prior authorization requests on February 24, 2025, for dates of service on or after March 1, 2025.

Members included in the new program

Updates to Carelon Medical Benefits Management programs apply to select local fully insured members and members covered under self‑insured (ASO) benefit plans with services medically managed by Carelon Medical Benefits Management. This notice does not apply to certain HMO, BlueCard®, Medicare Advantage, Medicaid, Medicare supplemental, or Federal Employee Program® (FEP^®) plans. For more information, please contact the phone number on the back of the member ID card. 

Pre‑service review requirements

For procedures scheduled to begin on or after March 1, 2025, all care providers must contact Carelon Medical Benefits Management to obtain a pre‑service review for the services, including, but not limited to, the following non‑emergency modalities. Please refer to the Clinical Guidelines at Anthem.com > Providers > Provider Resources > Policies, Guidelines & Manuals for complete code lists.

Note: All codes will be reviewed for medical necessity for the requested service and not for site of care.

To determine if prior authorization is needed for a member on or after March 1, 2025, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Care providers using the Interactive Care Reviewer (ICR) tool on http://Availity.com/ to pre‑certify an outpatient procedure will receive a message referring the provider to Carelon Medical Benefits Management. (Note: ICR cannot accept prior authorization requests for services administered by Carelon Medical Benefits Management.)

Care providers should continue to submit pre‑service review requests to Carelon Medical Benefits Management using the convenient online service provided on the Carelon Medical Benefits Management provider website. The website is available 24 hours a day, seven days a week, and processes requests in real time using Clinical Criteria. Go to https://www.providerportal.com/ to register.

For more information

For resources to help your practice get started with the cardiology, musculoskeletal, radiology, sleep, surgical procedures, and radiation oncology programs, visit:

Cardiovascular Solution | Carelon Insights

Radiology Solution | Carelon Insights

Sleep Solution | Sleep Healthcare | Carelon Insights

Surgical Procedures Solution | Carelon Insights

Radiation Oncology Solution | Carelon Insights

Additional Outpatient Utilization Management

Sign up at provider training for provider training for the additional outpatient UM:

• Wednesday, February 5, 2025, at 12 p.m. ET/11 a.m. CT
• Wednesday, February 12, 2025, at 12 p.m. ET/11 a.m. CT
• Friday, February 21, 2025, at 11 a.m. ET/10 a.m. CT
• Wednesday, February 26, 2025, at 12 p.m. ET/11 a.m. CT
• Wednesday, March 5, 2025, at 12 p.m. ET/11 a.m. CT

Our website, Anthem.com, provides information and tools such as order entry checklists, Clinical Guidelines, and FAQ. You can also contact your provider relationship management representative if you have any questions.

Through genuine collaboration, we can simplify access to care and help you deliver high‑quality, equitable healthcare.