Utilization management: prioritizing appropriate care and transparency

As a healthcare provider, staying informed about the utilization management (UM) process is crucial for optimizing patient care and streamlining administrative functions and claims submissions. This comprehensive guide details submission methods, necessary documentation, and contact information, ensuring you have the resources to facilitate approvals efficiently.

Support and communication

We have staff available to help with UM issues Monday through Friday during regular business hours for inbound collect or toll‑free calls. We can also receive fax communications after regular business hours. Phone and fax number options are detailed below. Messages will be returned within one business day. When initiating or returning calls, our staff will identify themselves by name, title, and organization name. TDD/TTY and language assistance services are available for members as needed at no cost.

You can access Medical Policies and Clinical UM Guidelines online here. You can also request a free copy of our UM criteria from our Medical Management department. Care providers can discuss a UM denial decision with a physician reviewer by calling us toll­free at the numbers listed below. You can request a peer‑to‑peer review by calling 262‑523‑2425.

Preapprovals

You can submit preapproval requests in the following ways:

• Phone: 855‑558‑1443
• Fax: 800‑964‑3627

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept preapproval requests. Secured voicemail is available outside of business hours.

Our UM decisions are based on the appropriateness of care and service and existence of coverage. We do not reward practitioners or other individuals for not approving coverage. We also do not offer financial incentives for UM decision‑makers to encourage decisions resulting in underutilization.

What if I need assistance?

If you have questions about utilization decisions or the UM process, call our Clinical team at 855‑558‑1443, Monday through Friday from 8 a.m. to 5 p.m. CT.

For additional support, visit the Contact Us section at the bottom of our website at https://providers.anthem.com/wi for the appropriate contact.