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. Anthem Blue Cross and Blue Shield (Anthem)’s 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, then select the Providers tab at the top of the webpage > under Provider Resources select Policies, Guidelines & Manuals > select your state > scroll down and select View Medical Policies and Clinical UM Guidelines.

 

We work with providers to answer questions about the UM process and the authorization of care. Here’s how the process works:

• Call us toll free from 8:30 a.m. to 5:00 p.m. Eastern time, Monday through Friday (except on holidays). More hours may be available in your area. Federal Employee Program hours are 8:00 a.m. to 7:00 p.m. Eastern time.
• If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after 12 midnight will be returned the same business day. 
• Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.

 

Our UM 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 UM requirements, operational review procedures, and discuss UM decisions with you.

 

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.

 

The following phone lines are for physicians and their staffs. Members should call the customer service number on their health plan ID card.

 

	To discuss UM Process & Authorizations	To discuss Peer-to-Peer UM Denials /Physicians	To request UM Criteria	Business Hours
Indiana	800-345-4348 877-814-4803   Transplant 800-824-0581   Behavioral Health 866-582-2293   Autism 844-269-0538	888 870 9342   Adaptive Behavioral Treatment 844-269-0538   National 800-821-1453; 866-776-4793	877-814-4803   Behavioral Health 866-582-2293	8:30 a.m. – 5:00 p.m. ET Monday through Friday (except on holidays).  More hours may be available in your area.
Kentucky	800-568-0075   KEHP 844-402-5347   Transplant 800-824-0581   Behavioral Health 866-582-2293   Autism 844-269-0538	877-814-4803   Adaptive Behavioral Treatment 844-269-0538   National: 800-821-1453; 866-776-4793; 888-870-9342	877-814-4803   Behavioral Health 866-582-2293	8:30 a.m. – 5:00 p.m. ET Monday through Friday (except on holidays).  More hours may be available in your area.
Missouri	800-992-5498 866-398-1922   Transplant 800-824-0581   Behavioral Health 866-302-1015   Autism 844-269-0538	800-992-5498 866-398-1922   CDHP/Lumenos 866-398-1922   Adaptive Behavioral Treatment 844-269-0538   National 800-821-1453; 866-776-4793	800-992-5498 866-398-1922   Behavioral Health 866-302-1015	8:30 a.m. – 5:00 p.m. ET Monday through Friday (except on holidays).  More hours may be available in your area.
Ohio	800-752-1182   Transplant 800-824-0581   Behavioral Health 866-582-2293   Autism 844-269-0538	877-814-4803   Adaptive Behavioral Treatment 844-269-0538   National: 800-821-1453; 866-776-4793	877-814-4803   Behavioral Health 866-582-2293	8:30 a.m. – 5:00 p.m. ET Monday through Friday (except on holidays).  More hours may be available in your area.
Wisconsin	800-242-1527  800-472-6909 800-472-8909 866-643-7087   Transplant 800-824-0581   Behavioral Health 866-302-1015   Autism 844-269-0538	800-242-1527 800-472-6909 866-643-7087   Adaptive Behavioral Treatment 844-269-0538   National 800-821-1453 866-776-4793	800-242-1527 800-472-6909   Behavioral Health 866-302-1015	8:30 a.m. – 5:00 p.m. ET Monday through Friday (except on holidays).  More hours may be available in your area.
FEP	800-860-2156 Fax: 800 732-8318 (UM) Fax: 877 606-3807 (ABD)	800-860-2156	800-860-2156 Fax: 800 732-8318 (UM) Fax: 877 606-3807 (ABD)	8:00 a.m. – 7:00 p.m. ET.

 

 

TTY Information

 

		TTY	Voice
Indiana	711 or	1-800-743-3333 (V/T)	1-800-743-3333 (V/T)
Kentucky	711 or	1-800-648-6056 (T/ASCII/HCO)	1-800-648-6057 (V)
Missouri	711 or	1-800-735-2966 (TTY/ASCII)	1-866-735-2460 (V)
Ohio	711 or	1-800-750-0750 (TTY/Voice/HCO)	1-800-750-0750 (TTY/Voice/HCO)
Wisconsin	711 or	1-800-947-3529 (TTY/HCO)	1-800-947-6644 (V)

 

827-1220-PN-CNT