Medical management model

Utilization Management

Anthem Blue Cross and Blue Shield’s (Anthem) Utilization Management (UM) program uses an integrated approach based on the physical, behavioral, and social needs of members. The UM program, in collaboration with other departments such as Care Management and Conditional Care, facilitates the delivery of the most appropriate medically necessary care to members in the most cost-effective, least-restrictive setting.

By collecting individualized data from intake information upon enrollment, historical claims data, and ongoing concurrent review, we develop a predictive model that stratifies members into levels of care that determines the level of intervention. Stratification is refined and targeted to those conditions and episodes of care that are most impactful. The care plans developed based on this information are specific to member needs. The members’ provider(s) are also engaged in the development and execution of their plan, so the care is integrated across physical, behavioral, and social spectrums.

Care management model

Our member-centric care management model integrates behavioral, physical, and social factors into each individual member’s plan of care. Our model features the early identification of needs, continuous assessment of health, and a member home approach that promotes collaboration among members, family, service coordinators, provider, and community resources.

This approach to care management was specifically designed to meet the needs of Medicaid recipients.

To learn more about our UM program or our Care Management model, please see your provider manual or contact your provider representative.