Provider Manuals, Policies & Guidelines
Anthem Blue Cross and Blue Shield Medicaid (Anthem) is committed to supporting you in providing quality care and services to the members in our network. Here, you will find Anthem’s provider manuals, Guidelines for clinical Utilization Management (UM) and medical policies.
Provider manuals and quick reference guides
Anthem’s provider manuals provide key administrative information, details regarding programs that include the utilization management program and case management programs, quality standards for provider participation, guidelines for claims and appeals, and more.
Medical Policies and Clinical UM Guidelines
Medical Policies address the medical necessity of new services or procedures and new applications of existing services or procedures. Clinical UM guidelines focus on detailed selection criteria, goal length of stay, and location for generally accepted technologies or services.
We routinely update Medical Policies and Clinical UM Guidelines as part of the review process. Please visit Medical Policies & Clinical UM Guidelines: Full List on the main Anthem website to view or search for specific Medical Policies and Clinical UM Guidelines.
- August 2022 Clinical Utilization Management Guidelines
- November 2021 Clinical Utilization Management (UM) Guidelines
- August 2021 Clinical Utilization Management (UM) Guidelines
- May 2021 Clinical Utilization Management (UM) Guidelines
- 2022 Clinical Practice Guidelines
- November 2020 Clinical Utilization Management (UM) Guidelines
- Preventive Health Guidelines
- Associates Performing Utilization Reviews
- Clinical Criteria for Utilization Management Decisions - Core Process
- Clinical Information for Utilization Management Reviews - Core Process
- Concurrent Review (Telephonic and On-site) and On-site Review Protocol Process - Core Process
- Emergency Services - Core Process
- Health Care Management Denial - Core Process
- Member Appeals and Provider Medical Necessity/Administrative denial appeals
- Prohibiting the Use of Financial Incentives When Making Medical Necessity Determinations – Core Process
- Subcontract UM Delegation
- Post-Service Review (Retrospective Review) Policy
- Transplant Approval Policy – Solid Organ/BMT/Stem Cell
- Use of Board Certified Consultants Medical Behavioral Health
- Utilization Management - Medicaid Delegation and Oversight
- Utilization Management Clinicians Responsibilities
- HEDIS Desktop Reference Guide 2023
- HEDIS Coding Booklet 2022
- Quality Measures Desktop Reference for Medicaid Providers
- Administrative Denial Notification
- HEDIS Coding Tips
- HEDIS prenatal and postpartum care coding bulletin
- HEDIS Well Child and Immunization Coding Bulletin 2022
- HEDIS telehealth-eligible measures
Kentucky Cabinet for Health and Human Services: Department for Medicaid Services
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
DentaQuest is an independent company providing dental benefit management services on behalf of Anthem Blue Cross and Blue Shield Medicaid. EyeQuest is an independent company providing vision benefit management services on behalf of Anthem Blue Cross and Blue Shield Medicaid.