Clinical UM Guidelines notification

Anthem is pleased to provide you with our updated and new Medical Policies. Anthem will also be implementing changes to our Clinical Utilization Management (UM) Guidelines that are adopted for Nevada. The Clinical UM Guidelines published on our website represent the Clinical UM Guidelines currently available to all plans for adoption throughout our organization. Since local practice patterns, claims systems, and benefit designs vary, a local plan may choose whether or not to implement a particular Clinical UM Guideline. The link below can be used to confirm whether or not the local plan has adopted the Clinical UM Guideline(s) in question. Adoption lists are created and maintained solely by each local plan.

The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized below.

New Clinical Guidelines effective for service dates on and after October 1, 2024

The Medical Policies and Clinical UM Guidelines for Anthem are developed by our national Medical Policy and Technology Assessment Committee. The Committee, which includes medical directors and representatives for Anthem from practicing physician groups, meets quarterly to review current scientific data and clinical developments.

All coverage written or administered by Anthem excludes from coverage, services or supplies that are investigational and/or not medically necessary. A member’s claim may not be eligible for payment if it was determined not to meet medical necessity criteria set in Anthem’s Medical Policies. Review procedures have been refined to facilitate claim investigation.

Anthem’s Medical Policies and Clinical UM Guidelines for Nevada available online

The complete list of our Medical Policies and Clinical UM Guidelines may be accessed on Anthem’s website at anthem.com — Select Providers. Under the Provider Resources heading, select Policies and Guidelines. Select Nevada as Your State. Select View Medical Policies & UM Guidelines. Either enter key word or code or select the link for Full List page to search the policy for your inquiry.

To view the list of specific Clinical UM Guidelines adopted by Nevada, navigate to the View Medical Policies & UM Guidelines page. Scroll to the bottom of the page to the link titled Clinical UM Guidelines adopted by Anthem in Nevada.