Policies, guidelines, and manuals
Access information for assessing coverage options, medical policies, and more.
Provide quality care to our members
Wellpoint is committed to supporting you in providing quality care and services to the members in our network. On this page you can access information for assessing coverage options, Medical Policies, Clinical Utilization Management (UM) Guidelines, clinical practice guidelines and support for delivering benefits to our members.
Provider manuals
Our provider manuals outline key administrative information about our case management and UM programs, quality standards for provider participation, claims and appeal guidance, prior authorization requirements, and much more.
Medical Policies and Clinical UM Guidelines
Medical Policies address the medical necessity of new services or procedures and new applications of existing services or procedures. Clinical UM Guidelines focus on detailed selection criteria, goal length of stay, and location for generally accepted technologies or services.
Medical Policies and Clinical UM Guidelines
Documents
Clinical Practice Guidelines Matrix
Research & Guidelines: Drug Testing Guidelines for Substance Use Disorder & Chronic Pain
May 2020 Clinical Utilization Management Guidelines
August 2020 Clinical Utilization Management (UM) Guidelines
November 2020 Clinical Utilization Management (UM) Guidelines
February 2021 Clinical Utilization Management (UM) Guidelines
August 2021 Clinical Utilization Management (UM) Guidelines
February 2022 Clinical Utilization Management (UM) Guidelines
We routinely update Medical Policies and Clinical Utilization Management (UM) Guidelines as part of the review process. Please visit our full list of policies and guidelines to locate or search for specific medical policies and clinical UM guidelines.
Coding spotlights
Coding Spotlight: Pregnancy 101
Related information
Primary Care Provider Responsibilities and Access Standards
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We look forward to working with you to provide quality service for our members.