Medical Necessity Review Process
Anthem Blue Cross will work with you and your health care providers to determine what is or is not medically necessary and appropriate care and services. While the types of services requiring review and the timing of the reviews may vary, Anthem Blue Cross is committed to ensuring that reviews are performed in a timely and professional manner.
The review process follows the same procedures and timing as the benefit claim process. See the Claims and Appeals Process section. In addition:
  • All pre-authorization, pre-service, concurrent and retrospective reviews for medical necessity are screened by clinically experienced, licensed personnel (called "Review Coordinators") using pre-established criteria and Anthem Blue Cross Medical Policy. These criteria and policies are developed and approved by practicing providers not employed by Anthem Blue Cross, and are evaluated at least annually and updated as standards of practice or technology change. Requests satisfying these criteria are certified as medically necessary. Review Coordinators are able to approve most requests.
  • If the request fails to satisfy these criteria or medical policies, the request is referred to a Peer Clinical Reviewer. Peer Clinical Reviewers are health professionals who are clinically competent to evaluate the specific clinical aspects of the request and render an opinion specific to the medical condition, procedure and/or treatment under review. Peer Clinical Reviewers are licensed in California with the same license category as the requesting provider. When the Peer Clinical Reviewer is unable to certify the service, the requesting physician is contacted by telephone for a discussion of the case. In many cases, services can be certified after this discussion. If the Peer Clinical Reviewer is still unable to certify the service, your provider will be given the option of having the request reviewed by a different Peer Clinical Reviewer.
  • Only the Peer Clinical Reviewer may determine that the proposed services are not medically necessary or not appropriate.
  • Reviewers may be Anthem Blue Cross employees or an independent third party chosen at the sole and absolute discretion of Anthem Blue Cross.
  • You or your physician may request copies of specific criteria and/or medical policies by writing to the address shown on your Anthem Blue Cross identification card. Medical necessity review procedures may be disclosed to health care providers through provider manuals and newsletters.
A determination of medical necessity does not guarantee payment or coverage. The determination that services are medically necessary is based on the clinical information provided. Payment is based on the terms of your coverage at the time of service. These terms include certain exclusions, limitations, and other conditions. Payment of benefits could be limited for a number of reasons, including:
  • The information submitted with the claim differs from that given by phone;
  • The service is excluded from coverage; or
  • You are not eligible for coverage when the service is actually provided.