Policies, Guidelines, & Manuals
We’re committed to supporting you in providing quality care and services to the members in our network. Here you will find information for assessing coverage options, guidelines for clinical utilization management, practice policies, the provider manual, and support for delivering benefits to our members.
Medical Policies & Clinical UM Guidelines
Medical polices address the medical need for new services or procedures and new applications of existing services or procedures. Clinical utilization management (UM) guide=lines focus on selection criteria, length of stay, and location for generally accepted technologies or services.
Provider manual
Wellpoint’s Provider Manual provides information about key administrative areas, including policies, programs, quality standards, and appeals.
If you have any questions about the information in the Provider Manual, please contact your Network Consultant. Some policies or procedures may have changed since the time of publication. In the event of a conflict between this manual and your contract, the terms of your contract will supersede the manual.
This version is effective beginning 01/01/2025.
Provider manual
Our provider manual provides information about key administrative areas, including policies, programs, quality standards, and appeals.
Reimbursement policies
Our reimbursement policies are available to promote a better understanding of the claims editing logic that may impact payment.
Clinical practice guidelines
This index compiles guidelines published by third parties, and we recognize it for the diagnosis and treatment of specific clinical circumstances.
Coming soon
More resources
Preventive health guidelines
We publish guidelines for routine health measures that can help prevent 85% of illness and disease. Members can access this information at any time by using our online self-service tool.
Clinical practice guidelines
When it comes to their healthcare, members have certain rights and responsibilities. Learn about these to help your patients take an active role in their care.
Transparency statement
From time to time, as permitted by contractual or regulatory obligations, Wellpoint contracts with an outside entity to provide our members or providers with various services — such as Utilization Management or Case Management — on our behalf. In addition, we may use an entity outside of the United States to perform some select utilization management approvals.
We have a common goal of helping to ensure that your patients receive access to quality, evidence-based, efficient care. If you have questions about this statement, please contact your local Provider Call Center.
Interested in becoming a provider in the Wellpoint network?
As we build the Wellpoint site, we ask that you use the Simply Healthcare Plans, Inc. (Simply) signup page to join our network. When you select this button, it will route you to the Simply page, but your request will be processed for new Wellpoint providers.