Anthem has developed coverage guidelines that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the coverage guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Coverage guidelines do not constitute plan authorization, nor is it an explanation of benefits.
Coverage guidelines can be highly technical and complex and are provided here for informational purposes. The coverage guidelines do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Anthem members should discuss the information in the coverage guidelines with their treating health care providers. Please note that the doctors, hospitals, and other providers referred to in this document are independent contractors who exercise independent judgment and over whom Anthem has no control or right of control. They are not agents or employees of Anthem.
Medical technology is constantly evolving and these coverage guidelines are subject to change without notice, although Anthem will use good faith efforts to provide advance notice of changes that could have a negative impact on benefits. Additional coverage guidelines may be developed from time to time and some may be withdrawn from use. The coverage guidelines generally apply to all of Anthem’s fully insured benefits plans, although some local variations may exist. Additionally, some benefit plans administered by Anthem such as some self-funded employer plans or governmental plans, may not utilize Anthem coverage guidelines. Members should contact their local customer services representative for specific coverage information.
If you would like to request a hard copy of an individual coverage guideline, please contact the member's health plan at the number on the back of their identification card.
Anthem Clinical UM Guidelines
Anthem has developed clinical utilization management (UM) guidelines that serve as one of the sets of guidelines for coverage decisions. Anthem is also licensed to use MCG guidelines to guide utilization management decisions. This may include but is not limited to decisions involving pre-certification, inpatient review, level of care, discharge planning and retrospective review. The MCG guidelines Anthem is licensed to use include (1) Inpatient & Surgical Care (ISC), (2) General Recovery Care (GRG), (3) Recovery Facility Care (RFC), (4) Chronic Care (CC) and (5) Behavioral Health Care Guidelines (BHG). Anthem also has the right to customize MCG guidelines based on determinations by its Medical Policy & Technology Assessment Committee (MPTAC).
Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the clinical UM guidelines. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. A clinical UM guideline does not constitute plan authorization, nor is it an explanation of benefits.
Clinical UM guidelines can be highly technical and complex and are provided here for informational purposes. These guidelines do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Anthem members should discuss the information in the clinical UM guideline with their treating health care providers.
These guidelines address the medical necessity of existing, generally accepted services, technologies and drugs. Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular clinical UM guideline. While the clinical UM guidelines developed by Anthem are published on this web site, the licensed standard and customized MCG guidelines are proprietary to MCG and are not published on the Internet site.
Medical technology is constantly evolving, and clinical UM guidelines are subject to change without notice. Additional clinical UM guidelines may be developed from time to time and some may be withdrawn from use. Members should contact their local customer services representative for specific coverage information.
The doctors, hospitals, and other providers which are part of the network of providers referred to in this document are independent contractors who exercise independent judgment and over whom Anthem has no control or right of control. They are not agents or employees of Anthem.
If you would like to request a hard copy of an individual clinical UM guideline or MCG guideline, please contact the member's health plan at the number on the back of their identification card.
