Anthem Medical Policies & Clinical UM Guidelines
Welcome to Anthem’s Medical Policy & Clinical UM Guideline website. Our goal in creating this application is to provide you with ready access to electronic versions of medical policies and clinical UM guidelines.
Finding Medical Policies & Clinical UM Guidelines
Anthem medical policies are listed by the following categories under the tabs noted above:
| All Medical Policies|
| Policies by Type|
Anthem Clinical UM Guidelines are listed by the following categories under the tabs noted above:
| All UM Guidelines|
| Guidelines by Type|
You can locate a medical policy or clinical UM guideline by clicking on a category, or by browsing all medical policies or all clinical UM guidelines, or by using the search function.
Search for Medical Policies & Clinical UM Guidelines
Consumer Tools are a new group of documents that offer information on certain health services and procedures for which a review may occur based on Medically Necessary, Not Medically Necessary, Investigational, Cosmetic and Reconstructive criteria. Consumer Tools provide background information related to benefit decisions and also describe possible positive considerations and risks that will have to be weighed, to support care that is safe and appropriate. The documents also include questions that a doctor may wish to review with her/his patients, our members. We hope that these documents can help enhance the discussion between doctors and their patients (our members), to support informed health care choices related to some of our medical policies and clinical UM guidelines. To help find out if a health service and/or treatment will be covered, and to learn more about the member’s plan benefits, see the certificate of coverage or call the customer service number on the member ID card.
Customizations to MCG™ Care Guidelines
This document provides a summary of customizations to the MCG™ Care Guidelines 18th Edition (effective April 28, 2014).
This document provides a summary of customizations to the MCG™ Care Guidelines 19th Edition (effective April 27, 2015).
In preparation for the implementation of ICD-10 CM and ICD-10 PCS, we are updating medical policies and clinical UM guidelines on a quarterly basis to include proposed ICD-10 coding. The ICD-10 coding is included within the Coding section. Please note that at this time, the ICD-10 code list may not be all inclusive and is subject to change as Position Statements may be updated. Feel free to send comments regarding the ICD-10 coding using the Contact Us link below.
The following contact us e-mail address is for questions related to the research and development of medical policies and clinical Utilization Management (UM) guidelines found on this site. For those inquiries please use the following link: Contact Us
Please direct inquiries related to benefit coverage, new ID cards, billing practices, prior authorization, pre-determination or reimbursement and any other inquiries unrelated to medical policy or clinical guidelines to the local plan provider representative, billing/reimbursement department or Customer Service, as applicable, by calling the number listed on the member ID card. We will not be able to respond to those inquiries.