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 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.

 

WIBCBS-CM-012741-22-CPN12185