Important information about utilization management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as members’ coverage according to their health plans. 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’s coverage guidelines are available on our 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 scroll down and select Providers>Select Review Policies box>Scroll down and click on the View Coverage & UM Guidelines orange box to view 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. - 5 p.m., Monday through Friday (except on holidays). More hours may be available in your area.  Federal Employee Program hours are 8 a.m. – 7 p.m. Eastern.

 

• 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 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.

 

Discuss UM Process and Authorizations	Discuss Peer-to-Peer UM Denials with Physicians	Request UM Criteria
Check Member ID Card for provider number 800-533-1120 833-592-9956   Transplant: 800-824-0581   Behavioral Health: 800-991-6045   Autism: 844 269 0538   Federal Employee Program Phone: 800-860-2156   FAX: 855-757-7243 (UM)   FAX: 855-757-7242 (ABD)	1-800-533-1120  Prompts 2,5,4,4,1   1-833-592-9956 Prompts 2,3         Behavioral Health:  800-991-6045   Federal Employee Program Phone: 800-860-2156	1-800-533-1120  Prompts 2,5,4,4,1   1-833-592-9956 Prompts 2,3         Behavioral Health:  800-991-6045   Federal Employee Program Phone: 800-860-2156 FAX 855-757-7243 (UM) FAX 855-757-7242 (ABD)

 

TTY/TDD

711 or   TTY Voice 800-828-1120 (TTY) 800-828-1140(Voice)

 

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.