Our Quality Standards | Blue Cross Blue Shield Indiana

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Our Quality Standards: Striving To Do Better, Every Day

Your health is important to us. We work hard to make sure you can get great care when you need it.

We do this by:

Having programs and services to help make sure the quality of health care you get is even better.
Supporting pregnant members and new moms with tools and information.
Finding local programs in your community to help you get the services you need.
Hosting events to help you learn about your plan and get the most out of it.
Following state and federal rules.
Looking at our quality reports to find new ways to offer better care.

Learn More About Quality Management

Have questions about the Quality Management program?

Call us or write to us. We can talk to you about:

What quality management is
How we are doing and what our goals are
How we are working to make things better for you

We can also send you information on our Quality Management program.

Hoosier Healthwise, Healthy Indiana Plan

1-866-408-6131

Hoosier Care Connect

1-844-284-1797

Indiana PathWays for Aging

1-833-412-4405

TTY

711

Case Management: Helping You Manage All The Moving Pieces

Health care can be overwhelming

Our case managers can help make it easier. Your providers know how to help you with your care. It really helps if you know how to care for yourself, too. That’s what our case managers do.

As an Anthem member, we offer many different types of services. Your case manager works with you and your provider to set up a plan of care. You may already be working with a case manager and know how to contact them.

If you think you need case management services or need help contacting your case manager, call us at:

Hoosier Healthwise, Healthy Indiana Plan

1-866-408-6131

Hoosier Care Connect

1-844-284-1797

Indiana PathWays for Aging

1-833-412-4405

TTY

711

Our case managers may also call if:

You or your doctor thinks case management might help you.
You’ve just gotten out of the hospital and need help with follow-up visits to other providers.
You’re going to the emergency room (ER) often for non-urgent care that could be handled by your provider.
You call our 24/7 NurseLine and need more follow-up for ongoing care.
Serious physical problems and need more help
Behavioral health problems and need more help working with all of your providers.

Your case manager can also help with:

Setting up health care services.
Getting referrals and prior authorizations (approvals).
Checking your plan of care.

If we call you, a nurse or social worker will:

Always identify themselves with their name, title and position with Anthem.
Tell you about what we offer.
Talk to you about your health and how you’re handling different parts of your life.

Utilization Management: How We Make Choices On Care And Services

Sometimes, we need to make choices about how we pay for care and services.

This is called Utilization Management (UM).

Our UM program:

Looks at what, when and how much of our services are medically needed.
Always strives for the best possible health outcomes for our members.

Our UM program does not:

Tell providers to withhold or give you fewer services limiting or denying care.
Stop certain people from getting services.
Reward providers for limiting or denying care.

What should you do if Anthem won’t approve care you think you need?

You or your provider can ask us to take another look. We’ll let you and your provider know when we get your request. You can ask us to take another look at services that:

Are not approved.
Have been limited in the amount or length of time from what was requested.

Getting In Touch With Our Utilization Management Staff

Some Anthem services and benefits need prior approval. This means your provider must ask Anthem to approve the services he or she wants you to have.

Services that don’t need approval are:

Emergency care.
Care needed after a hospital stay.

Our Utilization Review team looks at approval requests. The team decides if:

The service is medically needed.
The service is one that is included in your Anthem benefits.

Do you have questions about an approval or a denial you got? Call Member Services.

Our Utilization Review team or your Case Manager can help answer your questions.

Hoosier Healthwise, Healthy Indiana Plan

1-866-408-6131

Hoosier Care Connect

1-844-284-1797

Indiana PathWays for Aging

1-833-412-4405

TTY

711

Your Opinion Matters!

Every year, we survey our members about the benefits we offer. If you get a survey in the mail, by email or phone, please complete it. Help us make your plan better.

New Technology In Medicine And Care

To make sure we are always using the latest medical treatment and equipment to help you feel your best, our medical director and providers look at all the latest medical changes. They look at:

Medical treatment and services.
Behavioral health treatment and services.
Medicines.
Equipment.

They also look at the most up-to-date medical and scientific writings.

With all this data, they consider:

If the changes are safe and helpful.
If these changes offer the same or better results than what is used today.

This work is done to help us decide if a new treatment or care should be added to your benefits.

You Have Rights And Responsibilities

As an Anthem member, you have rights and responsibilities. They are listed in your member handbook under member materials Do you need a printed copy of your member handbook? Call Member Services at

Hoosier Healthwise, Healthy Indiana Plan

1-866-408-6131

Hoosier Care Connect

1-844-284-1797

Indiana PathWays for Aging

1-833-412-4405

TTY

711

Appeals

You have the right to ask for an appeal if you don’t agree with our decision to deny or reduce a service. An appeal is when you ask us to
look again at the care we denied to make sure we made the right decision. Learn more about your appeal rights.
Learn more

Your Benefits And How To Get Medical Care

Are you looking to learn more about our services and benefits? Grab your member handbook under member materials.

Preventive health care

Find out how to help prevent many health issues and how to live a healthier life.

Preventive health care for women

Learn how to get access to women’s health specialists for regular and preventive health care services.

Benefits and access to care

Find out more about your benefits and how to get medical care.

Language help

Learn how to get our information in the language you use at home.

Pharmacy

Find out about your benefits and how to get the medicines you need.

Case management

Partner with a case manager to learn more about ways to get care for your health issues.

Member rights and responsibilities

Read about your rights and responsibilities.

Notice of Privacy Practices

Learn more about how we keep your private information safe.

Medical necessity

Find out how we decide if care is right for you based on the right coverage and correct levels of care and service.

Advance directives

Learn more about your right to use an advance directive (living will), to have one on file or on hand if you can’t tell others about the care you want to keep you alive. Your provider has advance directive forms and more information.

Your benefits include many medically needed services, such as:

Inpatient behavioral health services.
Outpatient behavioral health services.
Partial hospitalization.
Treatment and rehabilitative services.

See your member handbook to learn more about your benefits.

You don’t need a referral from your primary medical provider (PMP) to see a behavioral health specialist in your plan.

There are some treatments and services your behavioral health specialist must ask Anthem to approve before you can get them. For information about services that need preapproval, please see your member handbook.

Our Notice Of Privacy Practices

The notice tells you about how we may use and share your health data. It also tells you how to get this data

The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). Our Notice of Privacy Practices is in your member handbook as well as online.

Call Member Services if you want a copy of the Notice of Privacy Practices mailed to you at:

Hoosier Healthwise, Healthy Indiana Plan

1-866-408-6131

Hoosier Care Connect

1-844-284-1797

Indiana PathWays for Aging

1-833-412-4405

TTY

711

Not A Kid Anymore? It May Be Time For A New PMP

As you become an adult, your health care needs start to change

If you’re seeing a pediatrician, you may want to find a primary medical provider who treats adults. Adult PMP offices include:

Family practice.
General practice.
Internal Medicine.

Start by asking your current PMP for a recommendation for a new adult PMP. We’re here to help, too. You can change your PMP at any time. It’s easy with our Find a Doctor tool. Or call Member Services at: