Important information about utilization management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the members’ 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.

You can request a free copy of our UM criteria from Provider Services at 800-450-8753. 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, visit: anthembluecross.com/provider/policies/clinical-guidelines.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept precertification requests. Secure 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:

• Using the Availity Essentials Authorization application. Log in to Availity Essentials and select Patient Registration > Authorizations and Referrals. You can also access information previously mailed or faxed anytime in Availity Essentials.
• Faxing to 800-964-3627.
• Calling us at 800-450-8753.

Have questions about utilization decisions or the UM process?

Call Provider Services at 800-450-8753, Monday through Friday, from 8:30 a.m. to 5:30 p.m. ET. or use Chat with Payer from Payer Spaces on Availity Essentials.