Important information about 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/virginia-provider > Resources > Policies, Guidelines and 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.

We are staffed with clinical professionals who coordinate our members’ care. Staff are available during business hours, Monday through Friday, from 8:30 a.m. to 5 p.m. ET, to accept precertification requests. 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 name when initiating or returning calls regarding UM issues.

You can submit precertification requests by:

• Calling Provider Services at 800-901-0020.
• Faxing to 800-964-3627.
• Visiting Availity Essentials at Availity.com.

If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.