Level of Care medical necessity reviews for upper and lower endoscopy procedures begin October 1, 2020

Anthem is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better healthcare experience for consumers.

 

Effective with dates of service on or after October 1, 2020, members with commercial plans covered by Anthem will require a medical necessity review of the hospital outpatient level of care for certain upper endoscopy and colonoscopy procedures. The clinical guideline, Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services, CG-SURG-52, will apply to the review process. The review will be administered by AIM Specialty Health_® (AIM).

 

AIM will evaluate the clinical information in the request against CG-SURG-52, to determine if the hospital-based outpatient setting is the appropriate level of care for the endoscopy service. Your office may contact AIM to request a peer-to-peer discussion before or after the determination.

 

The level of care medical necessity review only applies to procedures performed in an outpatient hospital setting. This does not apply to requests for review of endoscopy performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.

 

For a complete list of procedures subject to the medical necessity level of care review, and additional information, such as Frequently Asked Questions, visit aimproviders.com/surgicalprocedures.

 

Submit a request for review

Starting Sept. 21, 2020, ordering providers may submit prior authorization requests for the hospital outpatient level of care for these procedures for dates of service on or after October 1, 2020 to AIM in one of the following ways:

• Access AIM ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number 866-714-1103, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

 

AIM will offer webinars, beginning in May, to provide information on navigating the AIM ProviderPortal_SM. To register for a webinar visit aimproviders.com/surgicalprocedures.

 

Please note, this review does not apply to the following plans: BlueCard_®, Federal Employee Program_® (FEP_®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.  

 

Note: In some plans “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “level of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will hereafter use “level of care.”

 

538-0720-PN-GA