Mental Health And Behavioral Health Information

We’re committed to deciding cases quickly. Here are types of reviews and time frames you can expect. (The maximum time allowed for a health plan to decide medical necessity once it gets the information needed.)

Non-urgent pre-service (before care):

• 5 business days for fully-insured and HMO/POS plans
• 15 calendar days for self-funded plans (unless otherwise stated in your Evidence of Coverage or benefit booklet)
• 72 hours for non-urgent prescription drug requests for fully-insured and HMO/POS plans

Urgent pre-service (before care):

• 72 hours
• 24 hours for urgent prescription drug requests for fully-insured and HMO/POS plans

Urgent inpatient or outpatient ongoing care (during care):

• 24 hours (in some cases) or no later than within 72 hours of getting a request

Retrospective/post-service (after care):

• 30 calendar days

Qualified licensed health care professionals and doctors from Anthem Blue Cross and the medical group (or their peers) review requests and give an opinion specific to a medical condition, procedure and/or treatment under review. If the reviewer is unable to decide the medical necessity of a request, he or she may call the requesting doctor or other provider to discuss the case. In many cases, medical necessity can be determined after this call.

Decisions are based on what is right for each member for the type of care and service. Medically necessary review decisions made by Anthem Blue Cross are based on:

• Anthem’s medical policy criteria and guidelines (reviewed at least once a year and updated as standards and technology change).
• Nationally recognized clinical guidelines approved by a committee including practicing doctors and health care professionals not employed by Anthem Blue Cross.
• Your health benefits.

Employees, consultants or other providers are not rewarded or offered money or other incentives for denying care or a service, or for supporting decisions that result in using fewer services. Also, Anthem doesn’t make decisions about hiring, promoting or firing these individuals based on the idea or thought that they will deny benefits.

If we find services are medically necessary, it doesn’t mean the service is paid for or covered. Payment is based on the terms of your coverage at the time of service. There are some exclusions, limitations and other conditions that are part of your benefits. You will find them in your Evidence of Coverage or benefit booklet.

Payment of benefits could be limited for a number of reasons, such as:

• Information included with the claim differs from that given at time of review.
• The service performed is not covered.
• You’re not eligible for coverage when the service is given.

If we find the service is not a medical necessity, you and your doctor or health care provider requesting it will be sent written notice within two business days of the decision. This written notice has:

• A clear and simple explanation of the reason for the decision.
• The name of the criteria and/or guidelines used to make the decision and instructions for how to get a written copy.
• Information on how to appeal the decision and about your rights to an independent medical review.
• Specific parts of the contract that exclude coverage if the denial is based upon benefit coverage.

Anyone can see our medical necessity guidelines for specific services.

View our guidelines here. 

You may also call 1-800-794-0838 to request a free paper copy of the guidelines used to determine your case. These guidelines are used by Anthem Blue Cross to authorize, change or deny benefits for people with similar illnesses or conditions. Specific care and treatment benefits vary based on individual need and covered benefits.

If a request for health care services is denied or modified, you may have the right to ask Anthem to review the decision by filing a grievance or appeal. You can learn more about your rights, how to submit a grievance or appeal, and the review process on our Complaints and Grievances page.

To learn more about a UM medical decision, pre-authorization requests or the UR process, or if you have questions or issues, call our toll-free number: 1-800-274-7767, Monday through Friday (except holidays) from 8:00 a.m. to 5:00 p.m. Pacific Time.

If you call after hours or don’t reach someone during business hours, leave a confidential voice mail message with your name and phone number. We’ll return your call no later than the next business day, unless you request another time. Calls received after midnight will be returned the same business day.

You also can call Member Services at the number on your ID card to ask for an interpreter in your preferred language. They can read UM information in another language or help explain it in your preferred language free of charge.

If you have a hearing or speech loss, call 711 to use the National Relay Service or the number below for the California Relay Service. A special operator will contact Anthem to help with your needs.

1-800-855-7100 (English TTY/English voice)