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Coverage & Clinical UM Guidelines, and Pre-Cert Requirements
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Coverage Guidelines

PW_M008656
Anthem Coverage Guidelines 
By clicking on “Continue” below, I acknowledge that I have read the following. 
Anthem has developed coverage guidelines that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the coverage guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Coverage Guidelines do not constitute plan authorization, nor is it an explanation of benefits.  
Coverage Guidelines can be highly technical and complex and are provided here for informational purposes. Coverage guidelines do not constitute medical advice or medical care. Treating health care professionals are solely responsible for diagnosis, treatment and medical advice. Anthem members should discuss the information in the coverage guidelines with their treating health care professionals.  
Medical technology is constantly evolving and these coverage guidelines are subject to change without notice, although Anthem will use good faith efforts to provide advance notice of changes that could have a negative impact on benefits. Additional coverage guidelines may be developed from time to time and some may be withdrawn from use. The coverage guidelines generally apply to all of Anthem’s fully-insured benefits plans, although some local variations may exist. Additionally, some benefit plans administered by Anthem such as some self-funded employer plans or governmental plans, may not utilize Anthem coverage guidelines. Members should contact their local customer services representative for specific coverage information. 
The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom Anthem has no control or right of control. They are not agents or employees of Anthem. 
If you would like to request a hard copy of an individual coverage guideline, please contact the member's health plan at the number on the back of their identification card. 
 
Anthem Clinical UM Guidelines 
Anthem has developed clinical UM guidelines that serve as one of the sets of guidelines for coverage decisions.  Anthem is also licensed to use MCG™ guidelines (formerly known as Milliman Care Guidelines®) to guide utilization management decisions. This may include but is not limited to decisions involving pre-certification, inpatient review, level of care, discharge planning and retrospective review. The MCG™ guidelines Anthem is licensed to use include (1) Inpatient & Surgical Care Guidelines, and (2) General Recovery Care Guidelines. Anthem also has the right to customize MCG™ guidelines based on determinations by its Medical Policy & Technology Assessment Committee (MPTAC).  
Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the clinical UM guidelines.  Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. A clinical UM guideline does not constitute plan authorization, nor is it an explanation of benefits.  
Clinical UM guidelines can be highly technical and complex and are provided here for informational purposes. These guidelines do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Anthem members should discuss the information in the clinical UM guideline with their treating health care providers. 
The clinical UM guidelines published on this web site represent the clinical UM guidelines currently available to all health plans throughout our enterprise.  These guidelines address the medical necessity of existing, generally accepted services, technologies and drugs.  Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular clinical UM guideline.  While the clinical UM guidelines developed by Anthem are published on this web site, the licensed standard and customized MCG™ guidelines are proprietary to MCG™ and are not published on the Internet site.  
Medical technology is constantly evolving and clinical UM guidelines are subject to change without notice.  Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use.  Members should contact their local customer services representative for specific coverage information.  
The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom Anthem has no control or right of control.  They are not agents or employees of Anthem. 
If you would like to request a hard copy of an individual clinical UM guideline or MCG™ guideline, please contact the member's health plan at the number on the back of their identification card. 
PLEASE CONFIRM WHETHER THE APPLICABLE HEALTH PLAN HAS ADOPTED THE CLINICAL UM GUIDELINE IN QUESTION.  
Effective Dates of Coverage Guidelines and Specific Clinical UM Guidelines Adopted by Anthem Blue Cross and Blue Shield of Virginia
Behavioral Health Clinical UM Guidelines
Behavioral Health Release of Information Form
 
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©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use