Overview

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Medical Policies & Clinical UM Guidelines 
Welcome to UniCare’s medical policies & clinical UM guidelines website that provides access to electronic versions of medical policies and clinical UM guidelines. 
To view medical policies & clinical UM guidelines, click on the medical policy or UM guideline tab above. You can also use the “search” feature, which is now housed in the top navigation, or click this link: Click Here to Search 
To determine which clinical UM guidelines have been adopted by your plan, or to determine if there are applicable third party criteria, please click on the following link and scroll to the bottom of the page: Adopted Clinical UM Guidelines 
Dates associated with medical policies and clinical UM guidelines  
Each medical policy and clinical UM guideline includes a Last Review Date and Publish Date. A medical policy or clinical UM guideline is made available on our public websites on its Publish Date. While the Publish Date is enterprise-wide, the actual implementation date may differ, depending on notification requirements. Local health plans will determine if new or revised medical policies and clinical UM guidelines require advance provider notification, based upon state laws, provider contracts and other considerations.  
Medical policy and clinical UM guidelines do not contain an Implementation Date which is the date that a health plan may begin using the new or updated medical policy or clinical UM guideline. The Implementation Date may be the same as the Publish Date when an updated document is an expansion of current criteria. When a new document or an update to an existing document that is more restrictive is published, the Implementation Date is determined by the local health plan since requirements regarding provider notification vary based upon state laws, provider contracts and other considerations.  
Third Party Criteria
In addition to the documents we develop and maintain for coverage decisions, we may adopt clinical utilization management criteria (UM guidelines) developed and maintained by third party organizations. Please click on the UM Guidelines tab above and choose ‘By Category’ for information on the guidelines available for use. We have provided a link to Customizations to MCG Care Guidelines used by our plans below: 
MCG Care Guidelines: Anthem licenses and utilizes MCG care guidelines to guide utilization management decisions for some health plans. This may include but is not limited to decisions involving pre-certification, inpatient review, level of care, discharge planning and retrospective review. The MCG care guidelines licensed include (1) Inpatient & Surgical Care (ISC), (2) General Recovery Care (GRG), (3) Recovery Facility Care (RFC), (4) Chronic Care (CC) and (5) Behavioral Health Care Guidelines (BHG). 
Customizations to MCG Care Guidelines  
This document provides a summary of customizations to the MCG Care Guidelines 22nd Edition (publish date May 7, 2018).
Customizations to MCG Care Guidelines 22nd Edition
 
This document provides a summary of customizations to the MCG Care Guidelines 22nd Edition (publish date June 22, 2018). 
Customizations to MCG Care Guidelines 22nd Edition
 
 
Contact Us  
The process to contact us has been updated to help ensure the privacy and security of our members’ personal information.  
MEMBERS: Please call the toll-free Customer Service telephone number located on the back of your member ID card.  If you have created an online health insurance account, log in to submit your question through the online Message Center.  
PROVIDERS: Please call the toll-free Customer Service telephone number on the back of the member's ID card. Or, you may log on to the provider portal or contact your Network Relations Representative. 
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