AIM Musculoskeletal program expansion
AIM will follow the Anthem Blue Cross and Blue Shield (Anthem) clinical hierarchy for medical necessity determination. For Medicare Advantage (MA) products AIM makes clinical appropriateness based on CMS National Coverage Determinations, Local Coverage Determinations, other coverage guidelines, and instructions issued by CMS and legislative benefit changes. Where the existing CMS guidance provides insufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.
Prior authorization requirements
For services scheduled on or after November 1, 2020, providers must contact AIM to obtain prior authorization for the services detailed below. Providers are strongly encouraged to verify they have received a prior authorization before scheduling and performing services.
Detailed prior authorization requirements are available to contracted providers by accessing the Availity Portal* at www.availity.com. Contracted and non-contracted providers may call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements or additional questions as needed.
Small joint replacement (including all associated revision surgeries)
- Total joint replacement of the ankle
- Correction of hallux valgus
- Hammertoe repair
The expanded musculoskeletal program will review certain lower extremity small joint surgeries for clinical appropriateness of the procedure and the setting in which the procedure is performed (Level of Care review). Procedures performed as part of an inpatient admission are included. The clinical guidelines that have been adopted by Anthem to review for medical necessity and level of care are located at:
- AIM Small Joint Surgery Guideline
- AIM Level of Care Guidelines for Musculoskeletal Surgery and Procedures
How to place a review request
You may place a prior authorization request online via the AIM ProviderPortalSM. This service is available 24/7 to process requests using Clinical Criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 7 a.m. to 7 p.m. Central time.
For more information
For resources to help your practice get started with the musculoskeletal program, go to www.aimprovider.com/msk.
This provider website will help you learn more and provide useful information and tools such as order entry checklists, clinical guidelines, and FAQs.
For questions related to guidelines, please contact AIM via email at email@example.com.
August 2020 Anthem Provider News and Important Updates -- Colorado