Wisconsin – Anthem Medical Policies and Clinical UM Guidelines Update

December 2018 ~

Anthem Wisconsin has updated certain medical policies and clinical utilization management (UM) guidelines to support clinical coding edits.

The insurer notes that the following medical policies and Clinical UM Guidelines were developed or revised to support clinical coding edits. Several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.

Effective November 1, AIM Specialty Healthâ (AIM) Musculoskeletal Level of Care Guidelines, Sleep Study Guidelines and Radiology Guidelines will be used for clinical reviews.

When requesting services for a patient (including medical procedures and medications), the Precertification Look-Up Tool may indicate that precertification is not required, but this does not guarantee payment for services rendered; a Medical Policy or Clinical UM Guideline may deem the service investigational or not medically necessary. In order to determine if services will qualify for payment, please ensure applicable clinical criteria is reviewed prior to rendering services.

Medical Policies

The Medical Policy and Technology Assessment Committee (MPTAC) has approved the following Anthem medical policies.

Clinical Utilization (UM) Guidelines

The MPTAC approved the following Clinical UM Guidelines applicable to Anthem. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on August 31, 2018.

CPT^® is a registered trademark of the American Medical Association.

Source(s): Anthem Wisconsin Provider Communications;