Our Quality Standards
Your health is important to us. We work hard to make sure you can get great care when you need it. We do this by:
Our Quality Management program keeps track of Member Services and satisfaction.
Learn More About Quality Management
Have questions about the Quality Management program?
Call us. We can talk to you about:
- What quality management is.
- How we are doing and what our goals are.
- How we are working to make things better for you.
We can also send you information on our Quality Management program. Call
Care And Disease Management: Helping You Manage All The Moving Pieces
Healthcare can be overwhelming. Our case managers can help make it easier. Your providers know how to help you with your care. It really helps if you know how to care for yourself, too. That’s what our care managers do.
As an Anthem Blue Cross and Blue Shield member, we offer many different types of services. Your case manager works with you and your provider to set up a plan of care. You may already be working with a case manager and know how to contact them.
If you think you need care management services or need help contacting your case manager, call us at
Our case managers may also call if:
- You or your doctor thinks care management might help you
- You’ve just gotten out of the hospital and need help with follow-up visits to other providers
- You’re going to the emergency room (ER) often for nonurgent care that could be handled by your provider
- You call our 24/7 NurseLine and need more follow-up for ongoing care
- You have serious physical problems and need more help
- You have behavioral health problems and need more help working with all of your providers
Your case manager can also help with:.
- Setting up healthcare services
- Getting referrals and prior authorizations (approvals)
- Checking your plan of care
If we call you, a nurse or social worker will:
- Always identify themselves with their name, title, and position with Anthem
- Tell you about what we offer
- Talk to you about your health and how you’re handling different parts of your life
Utilization Management: How We Make Choices On Care And Services
Sometimes, we need to make choices about how we pay for care and services. This is called Utilization Management (UM).
Our UM program:
- Looks at what, when, and how much of our services are medically needed.
- Always strives for the best possible health outcomes for our members.
Our UM program does not:
- Tell doctors to withhold or give you fewer services limiting or denying care.
- Stop certain people from getting services.
- Reward doctors for limiting or denying care.
Getting In Touch With Our Utilization Management Staff
Some Anthem services and benefits need prior approval. This means your provider must ask Anthem to approve the services they want you to have. Services that don’t need approval are:
- Emergency care
- Follow-up doctor visits after a hospital stay
- Urgent care
- Family planning services
- Primary care services
- Women’s health care services
- Children’s screening services
- Services provided at local health departments
- Some mental health and substance use disorder services
Our Utilization Review team looks at approval requests. The team decides if:
- The service is medically needed.
- The service is one that is included in your Anthem benefits.
What should you do if Anthem won’t approve care you think you need? You or your provider can ask us to take another look. We’ll let you and your provider know when we get your request. You can ask us to take another look at services that:
- Are not approved.
- Have been limited in the amount or length of time from what was requested.
Do you have questions about an approval or a denial you got? Call Member Services at
Our Utilization Review team or your care manager can help answer your questions.
Your Opinion Matters!
Every year, we survey our members about the benefits we offer. If you get a survey in the mail, by email or phone, please complete it. Help us make your plan better.
New Technology In Medicine And Care
To make sure we are always using the latest medical treatment and equipment to help you feel your best, our medical director and providers look at all the latest medical changes. They look at:
- Medical treatment and services
- Behavioral health treatment and services
They also look at the most up-to-date medical and scientific writings. With all this data, they consider:
- If the changes are safe and helpful
- If these changes offer the same or better results than what is used today
This work is done to help us decide if a new treatment or care should be added to your benefits.
You Have Rights And Responsibilities
As an Anthem member, you have rights and responsibilities. They are listed in your member handbook. Do you need a printed copy of your member handbook? Call Member Services at 844-912-0938 (TTY 711).
Your Benefits And How To Get Medical Care
Are you looking to learn more about our services and benefits? Grab your member handbook! You can read about:
Find out how to help prevent many health issues and how to live a healthier life.
Preventive Healthcare For Women
Learn how to get access to women’s health specialists for regular and preventive health care services.
Benefits And Access To Care
Find out more about your benefits and how to get medical care.
Learn how to get our information in the language you use at home.
Partner with a care manager to learn more about ways to get care for your health issues.
Member Rights And Responsibilities
Read about your rights and responsibilities.
Notice Of Privacy Practices
Learn more about how we keep your private information safe.
Find out how we decide if care is right for you based on the right coverage and correct levels of care and service.
Learn more about your right to use an advance directive (living will), to have one on file or on hand if you can’t tell others about the care you want to keep you alive. Your provider has advance directive forms and more information.
Behavioral Health (Mental Health And Substance Use Disorder Services)
Sometimes, dealing with all of the demands of life, such as a home and family, can lead to stress. Stress can lead to depression and anxiety. It can also lead to marriage, family and/or parenting problems. Stress can also lead to unhealthy ways of coping such as alcohol and drug use.
If you or a family member is experiencing anxiety, depression, or difficulty managing alcohol or drug use, you can get help. Call Anthem Member Services at 844-912-0938 (TTY 711). You can also get the name of a behavioral health specialist who will see you if you need one.
Your benefits include many medically needed services, such as:
- Inpatient behavioral health services
- Outpatient behavioral health services
- Partial hospitalization
- Substance use treatment
- Crisis services
Learn more about your behavioral health benefits
You don’t need a referral from your primary care provider (PCP) to get these services or to see a behavioral health specialist in your plan.
If you think a behavioral health specialist does not meet your needs, talk to your PCP. They can help you find a different kind of specialist.
There are some treatments and services your PCP or behavioral health specialist must ask Anthem to approve before you can get them. Your doctor will be able to tell you what they are.
If you have questions about referrals and when you need one, contact Member Services at
Our Notice Of Privacy Practices
The notice tells you about how we may use and share your health data. It also tells you how to get this data. The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). View the Notice of Privacy Practices or find it in your member handbook. Call Member Services at 844-912-0938 (TTY 711) if you want a copy of the Notice of Privacy Practices mailed to you.
Not A Kid Anymore? It May Be Time For A New PCP Or Behavioral Health Provider.
It’s important for you to get the right care from your providers. As an adult, you can choose to change from a provider who specializes in care for children or teens to a provider who focuses on treating adults. This includes providers for physical and behavioral health. We can help if you want to change. We can also help you transfer your medical records.
Start by asking your current PCP or behavioral health provider for a recommendation for a new adult PCP or behavioral health provider. We’re here to help, too. You can change your PCP or behavioral health provider at any time. It’s easy with our Change Your PCP. Or call Member Services at 844-912-0938 (TTY 711).