Utilization management decisions based on appropriateness of care, benefits
This document states Anthem's principles for utilization management decisions, emphasizing decisions are based on appropriateness of care, service, and member coverage and that financial incentives do not encourage denial of care.
No material clinical or coverage changes in this revision.
Coverage Criteria
Anthem Blue Cross and Blue Shield does not base decisions to hire, promote, or terminate practitioners or other staff on the likelihood or perceived likelihood that those individuals will issue denials of benefits. Employment and personnel actions are governed by non‑discriminatory administrative principles that do not reward or incentivize issuing denials.
Provider Actions and Decision Basis
Decisions Based on Appropriateness and Coverage
Utilization management decisions are based only on the appropriateness of care and service and the member's coverage. Decisions about hiring, promoting, or terminating practitioners or staff are not based on the likelihood that they will support denials of benefits.
- Decisions are based on clinical appropriateness, benefits, and member coverage — not financial incentives.
Denial Risk — Financial Incentives Prohibited
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