Policies, Guidelines & Manuals

We’re committed to supporting you in providing quality care and services to the members in our network. Here you will find information for assessing coverage options, guidelines for clinical utilization management, practice policies, the provider manual and support for delivering benefits to our members.

Coverage Guidelines & Clinical UM Guidelines

Coverage guidelines address the medical necessity of new services or procedures and new applications of existing services or procedures. Clinical utilization management (UM) guidelines focus on detailed selection criteria, goal length of stay, and location for generally accepted technologies or services.

View Coverage Guidelines &
Clinical UM Guidelines

Provider Manual

Anthem's Provider Manual provides information about key administrative areas, including policies, programs, quality standards and appeals.

Download the Manual

Reimbursement Policies

Our reimbursement policies are available to promote a better understanding of the claims editing logic that may impact payment.

Access policies

Clinical Practice Guidelines

This index compiles guidelines published by third-parties and recognized by Anthem for the diagnosis and treatment of specific clinical circumstances.

Download the index

More Resources

Preventive Health Guidelines

We publish guidelines for routine health measures that can help prevent 85% of illness and disease. Members can access this information at any time by using our online self-service tool.

Review the guidelines

Member Rights and Responsibilities

When it comes to their health care, members have certain rights and responsibilities. Learn about these to help your patients take an active role in their care.

Read about member rights

Transparency Statement

From time to time, as permitted by contractual or regulatory obligations, Anthem contracts with an outside entity to provide our members or providers with various services—such as Utilization Management or Case Management—on our behalf. In addition, we may use an entity outside of the United States to perform some select utilization management approvals.

We have a common goal of helping to ensure that your patients receive access to quality, evidence-based, efficient care. If you have questions about this statement, please contact your local Provider Call Center.