Medical Management


Anthem’s medical management program serves to meet the quality management program’s medical management requirements. Providers receive information about the medical management program in the Provider Manual, and all Providers contracted with Anthem are required to cooperate with the program. The medical management program includes case management, disease management and pharmacy management, as well as Anthem Utilization Management Services, Inc. (AUMSI), the entity that provides utilization review and holds Anthem’s utilization review licenses in the states that require it. 
Medical and behavioral health utilization review services include the following: 
Pre-service review (pre-certification, pre-authorization, prospective review)
Concurrent review
Post-service (retrospective) review
Care management
In our medical management program, Anthem places special emphasis on member education and facilitating access to care that is appropriate in setting and intensity throughout the continuum of care. Periodic Provider surveys about utilization management processes assist us in identifying opportunities to improve our processes. 
Anthem’s medical management program encompasses medical services delivered by primary care physicians (PCPs), specialty care physicians, managed behavioral health clinicians and a wide variety of other health care practitioners. The scope of these services includes, but is not limited to, the following: 
Inpatient care to include elective and emergency admissions
Outpatient/ambulatory care procedures
Select office-based services and procedures
Ancillary services, including diagnostic services, provided in a hospital setting
Alternative care, e.g., skilled nursing facility, hospice, rehabilitation and home health services, including home infusion therapy and durable medical equipment
Referrals to out-of-network specialist providers.
Care management
Pre-service, concurrent and post-service reviews are the key components of medical management. Pre-certification, pre-authorization and prospective reviews are terms used by Anthem and are examples of pre-service decisions. Retrospective review is a term used by Anthem and is an example of a post-service decision. In making medical necessity determinations that are consistent with Anthem members’ benefit contracts and currently accepted standards of care, physician reviewers follow Anthem’s established criteria and guidelines when available and applicable to the member’s situation. These include Milliman USA Healthcare Management Criteria as adapted for Anthem’s business operations, Anthem utilization review/medical review guidelines, Anthem corporate medical policy, and other decision-support material. When no criteria are available or applicable to the clinical scenario, physician reviewers make a determination based on the available information and their independent clinical judgment. Medical policies are available at Anthem provides communication services at 800-797-7758 so practitioners can reach Anthem associates if they have questions about the utilization management process.  
Providers are contractually obligated to cooperate with Anthem in conducting medical management reviews and shall respond to inquiries from Anthem. Failure to respond within a reasonable timeframe may result in termination of your Provider Agreement. 
Any data or information pertaining to the diagnosis, treatment or health of any member or applicant obtained by Anthem from such person or from any Provider shall be held in confidence and shall not be disclosed to any third person unless the disclosure meets at least one of the following conditions: 
The disclosure is in connection with utilization review or reports.
An appropriate release has been obtained.
The disclosure is required or permitted by law.
The disclosure is allowed as provided in the Anthem member’s certificate.
Milliman and Robertson health care Management Criteria
Anthem utilizes Milliman USA Healthcare Management Criteria to facilitate appropriate evaluation of medical necessity by including assessment of the member throughout the continuum of care. Utilization planning for all levels of care is emphasized. A synopsis of the criteria is available to Providers on request and free of charge by calling Anthem’s medical management department at 303-831-3238 or toll free at 800-797-7758. To facilitate proper and consistent application of criteria, an interrator reliability audit is performed for all clinicians issuing medical necessity decisions for Anthem. 
Pre-Service Review
Pre-service review (which Anthem may refer to as pre-certification, pre-authorization or prospective review) is the evaluation (utilizing established criteria) and review of inpatient and ambulatory medical services. It excludes medical emergencies. The process helps to ensure, before care is rendered, that the care and the care setting are clinically appropriate. Benefits will be paid only for appropriate medical care. It verifies benefit coverage and the appropriate level of care before an admission or care. Trained authorization coordinators and registered nurse care coordinators under the direction of Anthem’s physician advisor conduct pre-service review. 
The attending physician is responsible for having Anthem pre-certify elective and urgent outpatient surgery and hospital admissions. Pre-certifications must be approved before service or an inpatient admission, except in medical emergencies. Pre-certification requests must include: member name, date of birth, requesting provider, all applicable procedure and diagnosis codes, place of service and date(s) of service. 
When Anthem receives a pre-certification request for an outpatient procedure or hospital admission, member eligibility is verified and the treatment plan is evaluated to help ensure that the service is being provided in the most appropriate setting for benefit purposes. Upon approval of the inpatient admission, Anthem staff notifies the admitting physician and hospital of a certified length of stay. The approved length of stay is based on the diagnosis, the proposed treatment plan, and the Anthem or Milliman Care Guideline average length of stay for the condition.  
All unscheduled admissions or service requests that appear to be outside the scope of a member’s benefit contract, or that are non-compliant with delivery system or utilization management guidelines, are referred to a care coordinator for review. The care coordinator obtains the appropriate information about the member, attending physician, facility and any other necessary information and enters this information into a computerized managed care system so historical data is maintained and retrievable. Reviews not meeting utilization management guidelines are referred to Anthem’s physician advisor or the physician advisor’s designee for a determination of benefit coverage. 
In addition to outpatient surgeries and hospitalization, services requiring pre-certification by Anthem include specialty office visit referrals to non-participating providers and office-based and other outpatient procedures requiring special review. Services are subject to medical policy review, and an appropriate, board-certified specialty physician consultation may be required. 
Concurrent Review
Concurrent review is conducted to monitor institutional Provider services utilized during ongoing patient care to determine if such services and plans of treatment continue to meet guidelines for that level of care. Reviews not meeting pre-certification guidelines are referred to Anthem’s physician advisor or the physician advisor’s designee for a determination. The designated care coordinator may conduct concurrent review by telephone or on-site. Concurrent review also includes discharge planning and care management. 
Concurrent review is conducted to: 
Identify and refer potential quality of care issues to Anthem’s quality management department.
Refer potential catastrophic and targeted disease management cases to the appropriate care manager.
Screen for under-utilization and over-utilization
Screen for post-discharge needs.
Collaborate with the Providers of care, the patient and significant others to arrange for alternative care and post-discharge needs.
Discharge planning coordinates a member’s continued care needs upon discharge from the inpatient setting. The initial evaluation begins prospectively or early in an inpatient stay. A comprehensive discharge plan includes assessment of the member’s total potential discharge needs. 
Care Management
Care management is a process for managing acute and chronic medical conditions, including unexpected catastrophic occurrences, with a focus on timely proactive and collaborative coordination of services for individuals with complex medical conditions or risk.  
The care management process extends the discharge planning process for members identified as needing coordination of a comprehensive or multi-faceted medical care management program. Care management can be instrumental in aligning the interest of and creating sustainable relationships between Anthem, the member and the physician and other health care providers. This process is used for both inpatient and ambulatory care services. The focus includes managing long-term, chronic or catastrophic conditions to reduce the necessity for recurrent hospital admissions. An example includes a member who had a catastrophic event requiring rehabilitation upon discharge from acute. A care manager is available to help with discharge arrangements to an inpatient or outpatient rehabilitative setting, participating with care conference sessions, arranging DME needs, arranging home care needs, in addition to helping with the psycho-social and financial needs a member may experience resulting from a catastrophic event. 
Selection of patients for care management services may include, but is not limited to, the following: 
When coordination of multiple practitioners or multiple resources is required
When specific diseases/injuries necessitate ongoing monitoring or may require high-cost treatment or services
When a member’s benefits are exhausted or when care may exceed the benefits available for the member
When identifying particular diseases is needed to analyze patterns of care, membership demographics and assessment of interventions in order to develop best practices for managing chronic and/or avoidable diseases
A care manager is available at 303-226-6904 or toll free at 866-422-3661 to help you with the care management needs of your patients who are Anthem members. 
Specialty Care Management Programs 
Anthem’s prenatal program is an example of a specialty care management program available to assist with management of members with specialized needs. The prenatal program is available to all pregnant Anthem members in fully insured groups, and it provides risk-stratification, pregnancy education and 24-hour access to an obstetrical nurse call line. Pregnant members identified as high risk have the opportunity to have their care managed by experienced obstetrical nurses whose goal is to reinforce the OB/GYN’s treatment recommendations and interact with the patient between OB/GYN office visits. To enroll your Anthem patients in the program, please call 1-800-828-5891 as early in the pregnancy as possible.  At the time of the initial visit, you may assess eligibility and benefits, and call the Provider customer service unit in the Telephone/Address Directory section.  
Post-Service Review
Post-service review (which Anthem may refer to as retrospective review) is conducted to evaluate the appropriateness of provided services and the level of care after services are rendered. The review may occur before or after the initial payment determination and is not a function that automatically begins upon claims receipt. A Provider may request that Anthem perform a retrospective review. 
Services not meeting established utilization criteria will be referred to Anthem’s physician advisor or designated physician reviewer for a determination. Written or electronic documentation will be performed for all discussions between the physician advisor and the requesting Provider regarding clinical information for medical necessity determinations. 
Inpatient Concurrent Review
Observation Admission
There may be instances when a patient must be evaluated before a plan of care is established. These instances may include stabilization, evaluation, treatment and/or a diagnostic work-up to determine a diagnosis. To that end, an observation admission not to exceed one 24-hour period is allowed.  
In general, Anthem’s medical guidelines indicate that an observation admission should be initiated for the following diagnoses after failure of appropriate outpatient treatment: 
Abdominal pain
Chest pain R/O myocardial infarction
Chronic obstructive pulmonary disease
Congestive heart failure
Syncope/near syncope
Benefits are payable for inpatient admissions after the 24-hour observation period if there is an inadequate response to initial treatment or if the member’s acuity justifies inpatient care. However, if Anthem’s physician advisor or designated physician reviewer approves observation admission benefits, all benefits for inpatient services will be denied. If it is determined that a member with approved observation status requires inpatient care, the inpatient care must be pre-certified. 
Telephonic Concurrent Review 
Upon Anthem’s receipt of your notification, facilities where concurrent review is conducted telephonically will require that clinical updates be provided on all members. When information is requested and not received, current policy states that within two business days of the due date or the receipt date, whichever is earlier, Anthem shall make a determination based on the available information and notify the Provider within one business day of making the initial determination.  
When information is requested and received, Anthem will proceed with the clinical review. The designated care coordinator will advise the facility’s utilization review representative of the authorized length of stay. The facility representative will be required to provide a clinical update no later than the close of business on the last certified day if additional inpatient days are required. Failure to provide Anthem with a clinical update will result in denial of any inpatient days beyond the last certified date. 
On-site Concurrent Review 
Facilities where concurrent review is conducted on-site will provide the designated care coordinator with access to records and with a daily census of all member admissions, a facility utilization management representative contact, a seating area to conduct concurrent review and telephone access. 
Concurrent reviews not meeting Anthem’s utilization management guidelines are referred to Anthem’s physician advisor or the physician advisor’s designee for a determination of benefit coverage. 
Adverse Determinations and Appeal Process
In cases of an adverse determination, the Provider may discuss the determination based on medical appropriateness and the application of benefits with one of Anthem’s physician reviewers. To reach a physician reviewer, the Provider may call Anthem’s medical management department at 303-831-3238 or toll free at 800-797-7758. Upon request, the Provider may obtain a synopsis of the criteria by calling Anthem’s medical management department at one of the phone numbers above. Medical policies are available at In addition, an expedited appeal may be requested when a delay in the appeal decision might be detrimental to the member’s health. Please see the member appeals policy in the Provider and Member Rights and Appeals section. 
Continuity of Care Guidelines
Anthem utilizes continuity of care guidelines when changes occur within the Provider network, as well as for new members and members with special needs and circumstances. The purpose of the guidelines is to help ensure that the medical and psychosocial needs of the member are met with minimal disruption to all involved parties. Continuity of care for members referenced above may be approved on a case-by-case basis up to 90 days in advance. 
Elements of Transition 
Early notification: Typically, a patient who is changing health plans involuntarily will experience a time delay between the notice of change and the effective date with the new Anthem plan. As soon as possible, the patient should advise the current physician practice about the change, and Anthem will coordinate with the previous health plan’s physician advisor and the nurse care managers to facilitate a smooth transition. During this transition period, Anthem will make the following available: 
A written description of its process for facilitating continuity of care
A written description of its review process for requests to continue services with an existing provider not contracted with Anthem
Identifying patients with special needs and circumstances: Current physicians are expected to identify patients who have unique needs and initiate a process to facilitate their transition to a new Provider, or to continue to provide the care when the Provider is terminating the Provider’s contract with Anthem and will no longer be a contracted Anthem Provider. 
If requested by the patient and to ease referral and physician selection, Anthem will provide a list of available participating Providers and information for contacting those Providers. A nurse care manager will be available to facilitate and verify that continuity of care has occurred.
If requested by the patient, it’s appropriate for the current physician to suggest a physician to the patient and then to begin communication with that physician.
Transition planning visit: During the period before Anthem coverage is effective, the current physician and patient should schedule a visit to facilitate a smooth transition to the accepting physician’s practice. An Anthem nurse care manager will be available to provide assistance during this transition. 
Transfer of patient information: The current treating physician should: 
Collect and prepare for the transfer of adequate medical records to inform the accepting physician of the patient’s past medical history, treatment modes, medication history, pertinent diagnostic measures, current treatment plan, etc.
Write a letter of referral summarizing pertinent historical and biographical data to facilitate the accepting physician’s development of rapport with the patient and the patient’s family.
The Anthem nurse care manager will be available to facilitate this communication process. 
Introductory visit to accepting physician: This may be arranged as soon as is practical after Anthem coverage becomes effective. The current treating physician should make a recommendation to the patient about the timeliness of scheduling the first appointment. The purpose is to begin developing relationships, to ensure that pertinent records are available, to transfer prescriptions if necessary and to consider ancillary needs. 
Physician-to-physician consultation: It may be appropriate for former and accepting physicians to formally consult about a patient’s unique needs. 
Compensation: Anthem will compensate the physician for covered services that are provided when Anthem coverage is in effect, in accordance with the physician’s Provider Agreement with Anthem. 
Clinical and operational transition guidelines: The nurse care manager handles the continuity of care process, which begins with a request from the patient, physician, plan administrator or previous carrier. 
Coordination of care and services, with specific case review, is set up with the previous carrier’s physician advisor 90 days in advance.
For a patient receiving inpatient care, continued coverage is provided for appropriate follow-up care with the non-plan physician, or with a physician Provider leaving the contracted Anthem Provider network.
Coordination of care is provided with the previous carrier’s behavioral health/substance abuse network for those patients for whom a course of treatment has been approved.
The following guidelines also apply when a physician is separating from Anthem: 
When a physician voluntarily leaves Anthem, the physician should initiate the transition process.
When Anthem initiates disaffiliation, Anthem will initiate the transition process.
Anthem will provide benefit level coverage in the following instances, if the care began before the effective date with Anthem and if the care would have been in-network under the previous carrier’s network: 
A pregnant member has had her first prenatal visit and/or she is in or beyond the 20th week of pregnancy.
Elective surgery was approved by the previous carrier’s pre-certification process, and the surgery was scheduled.
A member is receiving major ongoing treatment for an acute condition.
The previous carrier approved home health care and home IV therapy.
The previous carrier approved durable medical equipment.
A member is in a rehabilitation program.
A member has a life-threatening condition.
A member has a terminal illness.
Only medical care directly related to the condition for which the transition benefits have been granted will be paid at the in-network level. 
When an out-of-network provider is being treated as in-network, the Anthem nurse care manager will work with that provider and Anthem’s provider services department to negotiate case rates. 
The nurse care manager will individually manage participants with certain illnesses, injuries, treatments or medical conditions. If necessary, the nurse care manager will develop a transition plan detailing treatment and/or network physicians/clinics. 
In all cases, the decisions will be made in the best interest of the patient and the medical care being provided. 
The following are examples of situations when Anthem will apply continuity of care guidelines: 
Situation 1: A member is currently receiving long-term treatment from an out-of-network provider for a catastrophic illness. 
Health care management department staff will identify these cases, and the designated Anthem care manager will manage them. Members may continue their care without interruption for the specific condition for which they are being treated. If the provider treating this patient was considered in-network by the previous carrier, in-network coverage will continue until the member may be transferred to an Anthem in-network Provider. However, these members will be transferred to Anthem in-network Providers if and when appropriate. To determine if benefits will be paid at the in- or out-of-network level, the assigned care manager will review each case individually. 
Situation 2: A member is currently receiving treatment from an out-of-network provider (rehab, follow-up care, etc.) for a short-term illness. 
If the previous carrier considered these services in-network, Anthem will also consider the services in-network if they can be completed one month after Anthem coverage becomes effective. If services will not be completed one month after the Anthem effective date, the nurse care manager will review the case and make a determination. The care manager works jointly with the physician and the member to make the best decision for the member. If the member chooses to remain with the out-of-network provider, the member will receive no benefits, including point-of-service benefits, if applicable. 
Situation 3: A member enrolled with Anthem is not utilizing in-network Providers. 
Anthem’s customer service will help these members select a physician and follow Anthem’s guidelines to obtain benefits. If continuity of care is needed, the case will be referred to a care manager. If a member chooses to use out-of-network providers and not follow the guidelines as detailed in the member’s certificate, that member will not receive in-network benefits. 
Situation 4: A member is currently receiving maternity care and is transferring to Anthem. 
If the member is seeing an in-network provider with her previous carrier, receiving prenatal care, and in or beyond the 20th week of pregnancy, Anthem will consider the current provider in-network. 
If the member is seeing an out-of-network provider with her previous carrier and this provider is not contracted with Anthem, and the member is receiving prenatal care and in or beyond the 20th week of pregnancy, Anthem will consider the current provider in-network. 
Appropriate Service and Coverage
Participating Providers and utilization management decision-makers are required to help ensure that utilization management decisions are based only on the appropriateness of care and service and the existence of coverage. Providers or other individuals are not compensated for issuing adverse decisions related to coverage or service care, and financial incentives for utilization management decision-makers do not encourage decisions that result in underutilization/adverse decisions. 
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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use