Important Information about utilization management

Our utilization management (UM) decisions are based on written criteria, 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.  Anthem’s 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 select “Medical Policies, Clinical UM Guidelines, and Pre-Cert Requirements” from the Provider home page at anthem.com.

 

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.

 

To discuss UM Process and Authorizations	To Discuss Peer-to-Peer UM Denials w/Physicians	To Request UM Criteria	TDD/TTY
800-533-1120   Transplant 800-824-0581   Behavioral Health 800-991-6045   Autism 844 269 0538   FEP Phone 800-860-2156 FAX 855-757-7243 (UM) FAX 855-757-7242 (ABD)	1-800-533-1120  Prompts 2,5,4,4,1   Behavioral Health 800-991-6045   FEP Phone 800-860-2156	1-800-533-1120  Prompts 2,5,4,4,1   Behavioral Health  800-991-6045   FEP Phone 800-860-2156 FAX 855-757-7243 (UM) FAX 855-757-7242 (ABD)	711 Or TTY Voice 800-828-1120(T) 800-828-1140(V)

 

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.