Anthem Blue Cross and Blue Shield (Anthem) 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. Our coverage guidelines 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 Virginia > View Coverage Guidelines & 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 (FEP) hours are 8 a.m. to 7 p.m. ET.
  • 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.

 

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

 

Anthem in Virginia

 

To discuss UM Process

and Authorizations

To Discuss Peer-to-Peer

UM Denials w/Physician Denials w/Physicians 

To Request UM Criteria

 

TDD/TTY

 

Check Member ID Card for provider phone number

800-533-1120

833-592-9956

 

Transplant

800-824-0581

National Transplant

844-644-8101

Fax: 888-438-7051

 

Behavioral Health

800-991-6045

 

Autism

844 269 0538

 

FEP

800-860-2156

Fax: 855-757-7243 (UM)

Fax: 855-757-7242 (ABD)

1-800-533-1120 

1-833-592-9956

 

Peer-to-peer

804-354-3502

 

Behavioral Health

800-991-6045

 

Adaptive Behavioral Treatment

844-269-0538

 

FEP

800-860-2156

1-800-533-1120

1-833-592-9956

 

Behavioral. Health

800-991-6045

 

FEP

800-860-2156

Fax: 855-757-7243 (UM)

Fax: 855-757-7242 (ABD)

711, or

TTY: 800-828-1120

Voice: 800-828-1140

 

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.

 

1445-1221-PN-VA



Featured In:
December 2021 Anthem Provider News - Virginia