Important information about utilization management

Category: Medicaid

 

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. Our medical policies are available on our provider website at https://mediproviders.anthem.com/nv/pages/ medical-policies.aspx.

 

You can request a free copy of our UM criteria from Provider Services at 1-844-396-2330. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the number listed below. To access UM criteria online, go to https://mediproviders.anthem.com/nv/pages/medical-policies.aspx.

 

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 organization name when initiating or returning calls regarding UM issues.

 

You can submit precertification requests by:

• Faxing to:
  • o 1-866-920-8362 for durable medical equipment; physical therapy, occupational therapy and speech therapy; pain management; home care; home infusion; hyperbaric treatment; or wound care.
  • o 1-800-964-3627 for all other, including elective inpatient and outpatient services.
• Calling us at 1-844-396-2330.
• The Availity Portal at https://www.availity.com.

 

Have questions about utilization decisions or the UM process?

Call our Clinical team at 1-844-396-2330 Monday through Friday from 8 a.m. to 5 p.m. Pacific time.

 

ANV-NU-0050-19 April 2019