Policies, Guidelines & Manuals

We’re committed to supporting you in providing quality care and services to the members in our network. Here you will find information for assessing coverage options, guidelines for clinical utilization management, practice policies, the provider manual and support for delivering benefits to our members.

Medical Policies & Clinical UM Guidelines

 

Medical policies address the medical need for new services or procedures and new applications of existing services or procedures. Clinical utilization management (UM) guidelines focus on selection criteria, length of stay, and location for generally accepted technologies or services.

 

View Medical Policies & Clinical Guidelines 

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 

Provider Manual

 

Anthem's Provider Manual provides information about key administrative areas, including policies, programs, quality standards and appeals.

Download the Manual 

Reimbursement Policies

 

Our reimbursement policies are available to promote a better understanding of the claims editing logic that may impact payment.

Access policies 

Clinical Practice Guidelines

 

This index compiles guidelines published by third-parties and recognized by Anthem for the diagnosis and treatment of specific clinical circumstances.

 Download the index

More Resources

Preventive Health Guidelines

 

We publish guidelines for routine health measures that can help prevent 85% of illness and disease. Members can access this information at any time by using our online self-service tool.

 

Member Rights and Responsibilities

 

When it comes to their health care, members have certain rights and responsibilities. Learn about these to help your patients take an active role in their care.

 

Health Care Evaluations

 

There are several websites that can help members evaluate and select the best providers for their health care. We've listed and described those sites for easy access by you or your patients.

 

 

 Access evaluation websites

Long Term Services and Supports

 

We provide health care services for Medi-Cal Managed Care (Medi-Cal) members in certain California counties. Learn more about these services, which assist the elderly or those with disabilities with their daily needs.

 

 

 Learn about Medi-Care long term services

Transparency Statement

 

From time to time, as permitted by contractual or regulatory obligations, Anthem contracts with an outside entity to provide our members or providers with various services—such as Utilization Management or Case Management—on our behalf. In addition, we may use an entity outside of the United States to perform some select utilization management approvals.

 

We have a common goal of helping to ensure that your patients receive access to quality, evidence-based, efficient care. If you have questions about this statement, please contact your local Provider Call Center.

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We look forward to working with you to provide quality service for our members.

 

Payments for services from a non-participating provider are generally sent to the member, except where federal or state mandates apply, or negotiated agreements are in place.

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