CurrentAnthemPolicy N/A

Clinical Utilization Management Criteria — Indiana

This document lists Anthem Blue Cross and Blue Shield Clinical Utilization Management (UM) Criteria adopted for Indiana Medicaid programs and instructs providers on where to find criteria and how determinations are made.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Criteria — Indiana

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

Key ActionProviders must view individual Clinical UM Guidelines and Medical Policies on the Anthem provider site to determine prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~25listed Clinical UM Criteria/policies referenced

4named Indiana programs served (examples)

1primary source referenced (MCG)

Coverage Criteria and Guideline Adoption

Adoption and Use of Clinical UM Guidelines and Medical Policies

Adopted Clinical UM Guidelines and Medical Policies

General adoption and source: Anthem has adopted a list of Clinical UM Criteria for Indiana Medicaid programs and uses non-customized national clinical guidelines (MCG) as the primary source.

See Anthem provider site for individual criteria details.

Medical necessity determinations are made on a case-by-case basis using the Medicaid Clinical UM Guideline hierarchy for Indiana; if a request does not meet established criteria it will be referred to a licensed physician reviewer with appropriate clinical expertise.

Refer to the Anthem Clinical UM Guideline hierarchy and individual criteria links on the Anthem provider site for specific requirements.

Accessing individual criteria: The list of adopted Medical Policies and Clinical UM Guidelines is publicly available on the Anthem Medical Policy and Clinical UM Guideline website; providers must view the individual criteria via links to determine prior authorization requirements.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Criteria — Indiana

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

Key ActionProviders must view individual Clinical UM Guidelines and Medical Policies on the Anthem provider site to determine prior authorization requirements.

SourceLink

On This Page

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Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization and Criteria Availability

Prior authorization and clinical criteria are available on the Anthem Medical Policy and Clinical UM Guideline subsidiary website. Providers must review the individual Clinical UM Guidelines and Medical Policies that apply to the requested service. Note: Some items are denoted as new on the published criteria lists.

Non-customized national clinical guidelines (MCG) remain the primary UM criteria source.
We make determinations of medical necessity on a case-by-case basis in accordance with the Medicaid Clinical UM Guideline hierarchy for Indiana.

Documentation Required

Referral to Licensed Physician Reviewer When Criteria Not Met

If a request does not meet the established criteria guidelines, the case will be referred to a licensed physician reviewer for Indiana with the appropriate clinical expertise to make a determination of medical necessity. Providers should include complete clinical documentation with the initial request to avoid delays or denials.

Requests not meeting criteria are referred to an Indiana licensed physician reviewer.
Include supporting clinical records and rationale with prior authorization requests.

Note

Providers Contracted Through ACO/PMG/IPA

Providers who are contracted through an accountable care organization (ACO), participating medical group (PMG), or Independent Physician Association (IPA) must follow their group's guidelines and practices. This includes, but is not limited to, requirements for authorization, covered benefits and services, and claims submission. If you have questions, contact your group administrator or your Anthem network representative.

Applies to providers serving Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging when contracted through an ACO/PMG/IPA.
Group-level rules may supersede or augment Anthem requirements for authorization and claims handling.

Prior Authorization

Provider Actions — Operational Checklist

Actionable provider responsibilities: verify applicable Clinical UM Guidelines and Medical Policies before submitting requests; ensure documentation is complete and legible; use email signup for updates from Anthem; and contact your group administrator or Anthem network representative for questions about group-specific processes.

Verify and follow the Anthem Clinical UM Guideline hierarchy for Indiana.
Use http://anthem.ly/signup-abcbs-in to sign up for email updates.
Contact your ACO/PMG/IPA administrator for group-specific authorization or billing rules.

Key Definitions

Medical Necessity Determination

DefinitionMedical Necessity Determination: a case-by-case decision made using the Medicaid Clinical UM Guideline hierarchy for Indiana.

When usedApplied to individual requests for services under Indiana Medicaid programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging).

Outcome if criteria not metIf the request does not meet established criteria guidelines, it will be referred to the licensed physician reviewer for Indiana with appropriate clinical expertise to make a decision.

Primary evidence sourceNon-customized national clinical guidelines (MCG) are the primary source of UM criteria used in determinations.

Where to find criteria detailsIndividual Medical Policies and Clinical UM Guidelines are publicly available on the Anthem Provider Medical Policies site; links to criteria are provided in the Criteria Title column of the CUMG list.

CG-ANC-04	Ambulance Services: Air and Water
CG-ANC-07	Inpatient Interfacility Transfers
CG-DME-10	Durable Medical Equipment
CG-DME-13	Lower Limb Prosthesis
CG-DME-26	Back-Up Ventilators in the Home Setting
CG-MED-69	Inhaled Nitric Oxide
CG-SURG-82	Bone-Anchored and Bone Conduction Hearing Aids
CG-SURG-93	Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
CG-SURG-95	Sacral Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
CG-SURG-120	Vagus Nerve Stimulation

OpenPayer

Clinical Utilization Management Criteria — Indiana

Coverage Criteria and Guideline Adoption

Listed Clinical UM Criteria and Codes

Provider Responsibilities and Authorization

Background and Guideline Sources

Key Definitions