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. We do not 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 and UM Criteria are online at Home | Anthem Blue Cross and Blue Shield, or you can request a free copy of our UM Criteria by contacting the Medical Management department at 844-912-1226 or by emailing Anthem at ohiomedicaidprovider@anthem.com. Within seven calendar days of the date of denial, providers can discuss a UM denial decision with a physician reviewer by calling us toll-free at 833-308-3035.

We are staffed with appropriately qualified UM clinical professionals who are available by telephone from 8 a.m. to 5 p.m. ET, Monday through Friday, (except for the major holidays and two optional closure days, as required by contract) to coordinate our members’ care and render UM decisions for providers. Our UM review staff is available by telephone 24/7 to respond to authorization requests for inpatient admissions. 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 being with Anthem when initiating or returning calls regarding UM issues.

Please submit prior authorization requests, clinical information, and the member’s discharge date via Availity at Availity.com or fax to:

• Inpatient authorization fax numbers:
  • 877-643-0671 (Physical health)
  • 866-577-2184 (Behavioral health)
• Outpatient authorization fax numbers:
  • 877-643-0672 (Physical health)
  • 866-577-2183 (Behavioral health)

To expedite your request, use our prior authorization template form located here.

Have questions about utilization decisions or the UM process?

Call our clinical team at 844-912-1226, Monday through Friday from 7 a.m. to 8 p.m. ET.

Beyond simply signing a contract, care providers are part of a genuine collaboration aimed at improving the lives of real people.