Efficacy through efficiency — emphasizing utilization management

Utilization management (UM) decisions for Anthem HealthKeepers Plus members 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 are available on our provider website at https://providers.anthem.com/va > Resources > Policies, Guidelines & Manuals, or at this link.

You can request a free copy of our UM criteria from our Medical Management department. To access UM criteria online, go to link. Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the number listed below.

Our utilization management (UM) policies are designed to optimize clinical decision‑making and resource allocation so members can access efficient, cost-effective services. Please review the information below regarding the UM criteria decision process.

To submit preapproval requests:

• Online: Go to Availity Essentials at https://Availity.com
• Phone: 800‑901‑0020
• Fax: 800‑964‑3627

To discuss UM decisions or preapproval requests with a physician reviewer, contact Provider Services at 800-901-0020, Monday through Friday, from 8:30 a.m. to 5 p.m. ET. 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 organization when initiating or returning calls regarding UM issues.