Important information about utilization management

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. The Anthem Blue Cross and Blue Shield (Anthem) Medical Policies are available on Anthem’s website at Anthem.com.

You can also request a free copy of our UM criteria from our medical management department, and providers may discuss a UM denial decision with a physician reviewer by calling us at the toll-free numbers listed below. UM criteria are also available on the web. Just go to Anthem.com, and select For Providers > Provider Resources > Policies, Guidelines and Manuals > Select your state > View Medical Policies and 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^® hours are 8 a.m. to 7 p.m. Eastern.
• 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 simply 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 our company name when making or returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss utilization management decisions with you.