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 medical policies 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 Providers > Provider Resources > Policies, Guidelines and Manuals > Select your state > View Medical Policies and 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.
  • 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 Authorization

To Discuss Peer-to-Peer

UM Denials w/Physician

To Request UM Criteria

TTY/TDD

Business Hours

800-242-1527

800-472-6909

800-472-8909

866-643-7087

Fax: 866-959-2154

 

Transplant

888-574-7215

Fax: 866-255-2471

National Transplant

844-644-8101

Fax: 888-438-7051

 

Behavioral Health

866-302-1015

 

Autism

Call customer service number on back of member’s ID card.

 

FEP

800-860-2156

Fax: 800-732-8318 (UM)

Fax: 877-606-3807 (ABD)

888-870-9342

 

National

800-821-1453

866-776-4793

 

Behavioral Health

866-302-1015

 

Adaptive Behavioral Treatment

Call customer service number on back of member’s ID card.

 

FEP

800-860-2156

800-242-1527

800-472-6909

Fax: 866-959-2154

 

Behavioral Health

866-302-1015

 

FEP

800-860-2156

Fax: 800-732-8318 (UM)

Fax: 877-606-3807 (ABD)

711, or

 

TTY/HCO:

800-947-3529

 

Voice:

800-947-6644

Monday – Friday (except on holidays)

8:30 a.m. – 5 p.m.

 

More hours may be available in your area.

 

FEP

Monday – Friday

8 a.m. – 7 p.m. ET

 

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.

 

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Featured In:
December 2022 Anthem Provider News - Wisconsin