Important information about utilization management

Utilization management (UM) decisions for members enrolled in Anthem HealthKeepers Plus 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 underutilization. Our medical policies are available on our provider website at https://mediproviders.anthem.com/va/Pages/medical.aspx.

 

You can request a free copy of our UM criteria from our Medical Management department. To access UM criteria online, go to: 

https://mediproviders.anthem.com/va/Pages/medical.aspx 

Providers can discuss a UM denial decision with a physician reviewer by calling us toll free at the numbers listed below.

 

We are staffed with clinical professionals who coordinate our members’ care. Staff are available during business hours, Monday through Friday, 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 1-800-901-0020 or calling Anthem CCC Plus Provider Services at 1-855-323-4687.

 

• Faxing to 1-800-964-3627.

 

• Visiting https://www.availity.com.*

 

* Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

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