Important information about utilization management

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 mediproviders.anthem.com/nv/pages/medical-policies.aspx. 

 

You can request a free copy of our UM criteria from Provider Services at 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 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:

• Fax:
  • DME, physical therapy/occupational therapy/speech therapy, pain management, home care, home infusion requiring nursing services, insulin pumps, hyperbaric treatment, or wound care: 866-920-8362
  • Inpatient services: 844-442-8009
  • Outpatient services: 844-430-6807
  • Pharmacy prior authorization, including home infusion injectables, continuous glucose monitoring equipment, and diabetic supplies: 844-490-4876
• Phone: 844-396-2330
• Pharmacy: 844-396-2330
• Availity* Portal: availity.com

 

Have questions about utilization decisions or the UM process?

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

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Healthcare Solutions.

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