There are several factors that impact whether a service or procedure is covered under a member’s benefit plan. Medical policies and clinical utilization management (UM) guidelines are two resources that help us determine if a procedure is medically necessary. These documents are available to you as a reference when interpreting claim decisions.
To see a list of all medical policies and clinical UM guidelines, visit our Full List page.
Providers, improve your prior authorization and claims submission process. Our new online Clinical Documentation Lookup Tool (CDLT) gives real-time access to the highly recommended medical documents needed with submission.
Access the Clinical Documentation Lookup Tool
About These Policies
Medical Policies
Medical policiesspecific contract provisions
Clinical UM Guidelines
The clinical utilization management guidelines published on this website are not always used by all plans or lines of business. Clinical UM guidelines are available for adoption to review the medical necessity of services related to the guideline when the Plan performs a utilization review for the subject. Because practice patterns, claims systems and benefit designs vary, a local plan may choose whether to adopt a particular clinical UM guideline.
Commercial or FEP plans or lines of business which determine there is not a need to adopt a clinical utilization management guideline may instead use the guideline for educational purposes or to review the medical necessity of services for any provider who has been notified that his or her claims will be reviewed due to billing practices or claims that are inconsistent with other providers.
To determine which clinical utilization management guidelines have been adopted by your plan, or to determine if there are other applicable criteria, please reference the listing provided below.
Clinical UM Guidelines adopted by Anthem Blue Cross
Access Behavioral Health Provider Resources
Other Criteria
In addition to the documents Anthem Blue Cross maintains for coverage decisions, we may adopt criteria developed and maintained by other organizations. Note that where we have developed a medical policy that addresses a service also described in one of these other sets of criteria, Anthem Blue Cross’s medical policy supersedes.
- MCG Press Enter if MCG
- Carelon Medical Benefits Management Press Enter if Carelon Medical Benefits Management
- CarelonRx Press Enter if CarelonRx
- Carelon Post Acute Solutions Press Enter if Carelon Post Acute Solutions
Anthem Blue Cross 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 & Surgical Care
- General Recovery Care
- Recovery Facility Care
- Chronic Care
- Behavioral Health Care
Our member's Medicare plan may make coverage decisions using criteria from the clinical care guidelines provided by MCG Health. Visit the MCG Health website and follow the steps in their Coverage Guidelines tool to access the criteria:
Access the MCG Medicare Coverage Guidelines tool
Customizations to MCG Care Guidelines
This document provides a summary of customizations to the MCG Care Guidelines 26th edition (Publish date December 9, 2022).
Customizations to MCG Care Guidelines 26th Edition
This document provides a summary of customizations to the MCG Care Guidelines 27th edition (Publish date February 23, 2024).
Customizations to MCG Care Guidelines 27th Edition
This document provides a summary of customizations to the MCG Care Guidelines 28th edition (Publish date February 15, 2024).
Customizations to MCG Care Guidelines 28th Edition
Associated Dates
There are several different dates that may be associated with a medical policy or clinical utilization management guideline
Publish Date — the date a medical policy or clinical UM guideline was made available on our public websites
Last Review Date — the date a medical policy or clinical UM guideline was reviewed and approved
Note that while a publish date is enterprise-wide, the implementation date may differ depending on notification requirements. Please refer to the plan Provider Newsletter for more information relating to implementation dates.
