Important information about utilization management

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