We previously communicated that AIM Specialty Health® (AIM),* a separate company, would expand the AIM Musculoskeletal program to perform medical necessity review of the requested site of service for certain joint and interventional pain procedures beginning September 1, 2022. The expansion was delayed and will now be effective January 1, 2023, for Anthem Blue Cross and Blue Shield’s (Anthem) self-funded (administrative services only) group members, as further outlined below.

 

AIM will continue to manage the AIM Musculoskeletal program and level of care review. The AIM level of care guideline for musculoskeletal surgery and procedures is used for the level of care review. Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care). AIM will use the following Anthem Clinical Utilization Management Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The Clinical Criteria to be used for these reviews can be found by going to  https://www.anthem.com/provider/policies/ and selecting the appropriate state. Please note, this does not apply to procedures performed on an emergent basis.

 

A subset of the AIM Musculoskeletal program codes will be reviewed for site of care. A complete list of CPT® codes requiring prior authorization for the AIM Musculoskeletal site of care program is available on the AIM Musculoskeletal microsite. To determine if prior authorization is needed for an Anthem member on or after January 1, 2023, providers can contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers will be informed whether the AIM Musculoskeletal program applies. AIM will also have a file upload from the health plan of the in-scope membership and will not provide prior authorization for members who are out of scope. If providers use the Interactive Care Reviewer (ICR) tool on Availity* to pre-certify an outpatient musculoskeletal, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept prior authorization requests for services administered by AIM.)

 

Members included in the new program

This program will be available to a small colume of self-funded (administrative services only) groups that currently participate in the AIM Musculoskeletal program and have added the AIM Musculoskeletal site of care program to their members’ benefit package as of January 1, 2023. Program readiness was evaluated, and it was determined that we are not ready to launch for the fully insured membership. It will also expand to fully insured members currently participating in the AIM Musculoskeletal program at a future date. 

 

Pre-service review requirements

For surgeries that are scheduled to begin on or after January 1, 2023, all providers must contact AIM to obtain prior authorization review. The following groups are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, and the Federal Employee Program® (FEP®). 

 

For services provided on or after January 1, 2023, ordering and servicing providers may begin contacting AIM on January 1 for review. Providers may submit prior authorization requests to AIM in one of several ways:

  • Access AIM’s ProviderPortalSM directly at https://aimspecialtyhealth.com/providerportal. Online access is available 24/7 to process orders in real-time, and this is the fastest and most convenient way to request authorization.
  • Access AIM via Availity at www.availity.com.
  • Call the AIM Contact Center toll-free number at 877-430-2288, Monday through
    Friday, 8 a.m. to 6 p.m. ET.

 

Initiating a request on AIM’s ProviderPortalSM and entering all the requested clinical questions will allow you to receive an immediate determination. If the request is approved, you will receive the order ID, the number of visits, and valid time frame. The AIM Musculoskeletal program microsite on the AIM provider website helps you learn more, and you can access helpful information and tools such as order entry checklists.

 

AIM Musculoskeletal training webinars                                                                    

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM.  Go to the AIM Musculoskeletal microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.


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Featured In:
December 2022 Provider Newsletter - Connecticut