Medical Policies & Clinical UM Guidelines
There are several factors that impact whether a service or procedure is covered under a member’s benefit plan. Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. These documents are available to you as a reference when interpreting claim decisions.
Search for Medical Policies and Clinical UM Guidelines
To see a list of all medical policies and clinical UM guidelines, visit our Full List page.
Providers, improve your prior authorization and claims submission process. Our new online Clinical Lookup Tool (CDLT) gives real-time access to the highly recommended medical documents needed with submission.
About These Policies
Medical Policies
Medical policies are used by all plans and lines of business unless Federal or State law—as well as contract language, including definitions and specific contract provisions or exclusions—take precedence over a medical policy. Those provisions will be considered first in determining eligibility for coverage before the medical policy is used to determine medical necessity.
Clinical UM Guidelines
The clinical utilization management (UM) guidelines published on this website are not always used by all plans or lines of business. Clinical UM guidelines are available for adoption to review the medical necessity of services related to the guideline when the Plan performs a utilization review for the subject. Because practice patterns, claims systems and benefit designs vary, a local plan may choose whether to adopt a particular clinical UM guideline.
Commercial or FEP plans or lines of business which determine there is not a need to adopt a clinical utilization management guideline may instead use the guideline for educational purposes or to review the medical necessity of services for any provider who has been notified that his or her claims will be reviewed due to billing practices or claims that are inconsistent with other providers.
To determine which clinical utilization management guidelines have been adopted by your plan, or to determine if there are other applicable criteria, please reference the listing provided below.
Access your Clinical UM Guidelines
Other Criteria
In addition to the documents Anthem Blue Cross and Blue Shield maintains for coverage decisions, we may adopt criteria developed and maintained by other organizations. Note that where we have developed a medical policy that addresses a service also described in one of these other sets of criteria, Anthem Blue Cross and Blue Shield’s medical policy supersedes.
Associated Dates
There are several different dates that may be associated with a medical policy or clinical utilization management guideline
Publish Date — the date a medical policy or clinical UM guideline was made available on our public websites
Last Review Date — the date a medical policy or clinical UM guideline was reviewed and approved
Note that while a publish date is enterprise-wide, the implementation date may differ depending on notification requirements. Please refer to the plan Provider Newsletter for more information relating to implementation dates.
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Payments for services from a non-participating provider are generally sent to the member, except where federal or state mandates apply, or negotiated agreements are in place.