Important information about utilization management

Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.

 

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://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, 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:
  • o Provider Services: 800-901-0020.
  • o Anthem CCC Plus Provider Services: 855-323-4687.
• Faxing to 800-964-3627.
• Visiting Availity* Essentials at availity.com.

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) Provider Services at 855‑323‑4687.

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