Policies, guidelines and manuals
Locate information for assessing coverage options, guidelines for Clinical Utilization Management (UM), practice policies, and support for delivering benefits to our members.
Provider manual
The Anthem provider manual provides key administrative information, including the quality improvement program, the UM program, quality standards for participation, claims appeals, and reimbursement, and administration policies.
Provider Digital Engagement Supplement
Medical Policies and Clinical UM guidelines
Anthem uses nationally recognized, evidence-based Medical Policies and Clinical UM Guidelines.
Utilization Management Clinical Criteria
Clinical Utilization Management Criteria February 2023
Clinical Utilization Management Criteria May 2023
Clinical Utilization Management Criteria August 2023
Clinical Utilization Management Criteria November 2023
Clinical Utilization Management Criteria February 2024
Clinical Utilization Management Criteria May 2024
Clinical Utilization Management Criteria August 2024
Anthem licenses and utilizes MCG Care Guidelines to guide utilization management decisions for some health plans. This may include but is not limited to decisions involving prior authorization, inpatient review, level of care, discharge planning and retrospective review. MCG Care Guidelines licensed include:
- Inpatient and Surgical Care (ISC)
- General Recovery Care (GRG)
- Ambulatory Care (AC)
- Recovery Facility Care (RFC)
- Home Care (HC)
- Behavioral Health Care (BHG)
- Chronic Care Guidelines (CCG)
MCG and Anthem’s Medical Policies and Clinical UM Guidelines are available and can be requested by contacting Provider Services at 844-912-1226 or by emailing Anthem at ohiomedicaidprovider@anthem.com.
Codes
Medicaid managed care requirements can be found in the Ohio Administrative Code and Ohio Revised Code.
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