Provider manuals and guides

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.

Medical Policies and Clinical UM guidelines

Anthem uses nationally recognized, evidence-based Medical Policies and Clinical UM Guidelines.

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 .

Medicaid managed care requirements in the Ohio Administrative Code and Ohio Revised Code

Clinical practice guidelines

• Preventive health guidelines - Coming Soon