Insights on utilization management

Utilization management (UM) decisions are based on the appropriate care and services needed and the member’s coverage. We do not reward care providers or other people for issuing denials of coverage, service, or care. We do not make decisions about hiring, promoting, or terminating people 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 available on our website. You can also request a copy of our UM criteria at no cost to you by contacting the Medical Management department at 844‑912‑1226 or by emailing us at ohiomedicaidprovider@anthem.com. If you have questions about a UM decision, you can call a physician reviewer toll‑free at 833‑308‑3035.

Within seven calendar days of the claim not being accepted, care providers can discuss a UM denial decision with a physician reviewer by calling us toll‑free at 833‑308‑3035. This can help resolve issues quickly, ensuring minimal disruption to members' access to necessary care and services.

Accessing UM clinical professionals

We are staffed with qualified UM clinical professionals who are available at 844‑912‑1226 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). These people help coordinate our members’ care and render UM decisions.

Our UM review staff is available at 844‑912‑1226 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.

Using Availity Essentials

Submit prior authorization requests, clinical information, and member discharge dates through Availity Essentials at https://Availity.com. You may also fax them to:

• Inpatient authorization:
• 877‑643‑0671 (physical health)
• 866‑577‑2184 (behavioral health)
• Outpatient authorization:
• 877‑643‑0672 (physical health)
• 866‑577‑2183 (Behavioral health)
• Medical injectables:
• 800‑563‑5581 (inpatient and outpatient)

To expedite your request, use our prior authorization template form on https://providers.anthem.com/oh > Resources > Forms.

Have questions about the UM process?

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