Utilization Review Program
The Utilization Review Program evaluates the medical necessity and appropriateness of care and the setting in which care is provided. You and your physician are advised if it has been determined that services can be safely provided in an outpatient setting, or if an inpatient stay is recommended. Services that are medically necessary and appropriate are certified by Anthem Blue Cross and monitored so that you know when it is no longer medically necessary and appropriate to continue those services.
When your physician is a network provider, it is your physician's responsibility to start the Utilization Review Process before scheduling you for any service subject to the utilization review program. When your physician is a non-network provider, it is your responsibility to see that your physician starts the utilization review process before scheduling you for any service subject to the utilization review program. If you receive any such service and do not follow the procedures set forth in this subsection, your benefits may be reduced.
Utilization Review Requirements
Utilization reviews are required for:
  • Inpatient hospital admission stays. (A $300 penalty applies for not obtaining pre-authorization.)
    • Exceptions: Utilization review is not required for inpatient hospital stays for the following services:
      • Maternity care of 48 hours or less following a normal delivery or 96 hours or less following a cesarean section; and
      • Mastectomy and lymph node dissection.
  • Ambulatory Surgical Center and outpatient surgeries.
  • Home Infusion.
Review Stages
There are three stages of utilization review:
  • Pre-Service review determines the medical necessity and appropriateness of scheduled, non-emergency inpatient hospital admissions.
  • Concurrent review determines whether services are medically necessary and appropriate when pre-service review is not required or when Anthem Blue Cross is notified while service is ongoing, for example, after an emergency admission to the hospital.
  • Retrospective review is performed to review services that have already been provided.
    • This applies in cases when pre-authorization, pre-service or concurrent review was not completed, or in order to evaluate and audit medical documentation subsequent to services being provided. Retrospective review may also be performed for services that continued longer than originally certified.
Effect on Benefits
In order for the full benefits of the Plan to be payable, the following criteria must be met:
  • The appropriate utilization reviews must be performed in accordance with the Plan.
When pre-service review is not performed as required for an anticipated inpatient hospital admission, a $250 penalty will be applied. The services must be medically necessary and appropriate.
Inpatient hospital benefits will be provided only when an inpatient stay is medically necessary and appropriate. If you proceed to receive any services that have been determined to be not medically necessary or not appropriate at any stage of the utilization review process, benefits will not be provided for those services.
  • Services that are not reviewed prior to or during service delivery will be reviewed retrospectively when the bill is submitted for benefit payment.
If that review results in the determination that part or all of the services were not medically necessary or not appropriate, benefits will not be paid for those services. Remaining benefits will be subject to previously noted reductions that apply when the required reviews are not obtained.
How to Obtain Utilization Reviews
Remember, when your physician is a network provider, it is your physician's responsibility to confirm that the review has been performed. When your physician is a non-network provider, it is your responsibility to confirm that the review has been performed.
Pre-Service Reviews
Penalties will result for failure to obtain pre-service review before receiving scheduled services, as follows:
  • For all scheduled services that are subject to utilization review, you or your physician must initiate the pre-service review at least five working days prior to when you are scheduled to receive services.
  • Physicians who are network providers will initiate the review on your behalf. A non-network provider may initiate the review for you, or you may call Anthem Blue Cross directly. The toll-free number for pre-authorization and pre-service review is 800-274-7767. This number is printed on your ID card.
  • If you obtain certification for a service but the certified service is not rendered within 60 days of obtaining the certification, or if the nature of the service changes, a new pre-service review must be obtained.
  • Anthem Blue Cross will certify services that are medically necessary and appropriate. For inpatient hospital stays, Anthem Blue Cross will, if appropriate, certify a specific length of stay for approved services. You, your physician and the provider of the service will receive a written confirmation showing this information.
Concurrent Reviews
  • If pre-service review was not performed, you, your physician or the provider of the service must contact Anthem Blue Cross for concurrent review. For an emergency admission or procedure, Anthem Blue Cross must be notified within one working day of the admission or procedure, unless extraordinary circumstances prevent such notification within that time period.
    • In determining "extraordinary circumstances," Anthem Blue Cross may take into account whether or not your condition was severe enough to prevent you from notifying them, or whether or not a member of your family was available to notify Anthem Blue Cross for you. You may have to prove that such "extraordinary circumstances" were present at the time of the emergency.
  • When network providers have been informed of your need for utilization review, they will initiate the review on your behalf. You may ask a non-network provider to call the toll-free number printed on your identification card or you may call directly. The toll-free number for pre-authorization and pre-service review is 800-274-7767. This number is printed on your ID card.
When it is determined that the service is medically necessary and appropriate, Anthem Blue Cross will, depending upon the type of treatment or procedure, certify the service for a period of time that is medically appropriate. Anthem Blue Cross will also determine the medically appropriate setting.
If it is determined that the service is not medically necessary or not appropriate, your physician will be notified by telephone no later than 24 hours following Anthem Blue Cross' decision. Anthem Blue Cross will send written notice to you and your physician within two business days following the decision. However, care will not be discontinued until your physician has been notified and a plan of care that is appropriate for your needs has been agreed upon.
Retrospective Reviews
  • Retrospective review is performed when Anthem Blue Cross is not notified of the service you received, and is therefore unable to perform the appropriate review prior to your discharge from the hospital or completion of outpatient treatment. It is also performed when pre-service or concurrent review has been done, but services continue longer than originally certified.
  • Retrospective review may also be performed for the evaluation and audit of medical documentation after services have been provided, whether or not pre-service or concurrent review was performed.
  • Such services which have been retrospectively determined to be not medically necessary or not appropriate will be retroactively denied certification.