As we communicated in the October 2017 Network Update, AIM administers pre-service clinical reviews on behalf of Anthem for the services noted below. AIM reviews requests in real time against evidence-based clinical guidelines and Anthem medical policies. Providers are notified via letter or remit message when claims are submitted without the appropriate pre-service review by AIM. If such a letter or message is received, providers will need to obtain a post-service clinical review for the service via the AIM ProviderPortalSM.  If the documentation/post-service review request is submitted to Anthem, we notify the provider via another letter or remit message to submit to AIM.

 

AIM reviews the following services for clinical appropriateness:

  • Advanced diagnostic imaging
  • Cardiology tests and procedures (e.g. MPI, echocardiography, PCI, cardiac catheterization)
  • Medical oncology treatments through the Cancer Care Quality Program
  • Radiation oncology treatments (e.g. IMRT, brachytherapy)
  • Sleep testing, treatment and supplies
  • Genetic testing
  • Musculoskeletal (e.g., spine and joint surgeries, pain management)
  • Rehabilitative services (physical, speech and occupational therapy)
  • Surgical site of care (e.g., gastroenterology, other surgeries will be implemented which will be communicated via Provider News)

 

Services performed in an emergency or inpatient setting are excluded from AIM programs.

 

This update applies to local fully-insured Anthem members and members who are covered under a self-insured (ASO) benefit plan, with services medically managed by AIM. It does not apply to BlueCard, Medicare Advantage, Medicaid, Medicare Supplement or Federal Employee Program (FEP) members.

 

To help prevent delays in claim processing and post-service reviews, ordering providers should submit pre-service requests to AIM in one of the following ways:

 

  • Access AIM ProviderPortal directly at providerportal.com available 24/7 to process orders in real-time
  • Access AIM via the Availity web portal at availity.com

 

For more information, please contact the phone number on the back of the member’s ID card.

 

711-1120-PN-NE



Featured In:
November 2020 Anthem Connecticut Provider News