Anthem Blue Cross and Blue Shield

Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

 

Anthem Blue Cross and Blue Shield (Anthem) is expanding their partnership with AIM Specialty Health® (AIM) for outpatient rehabilitative and habilitative services.

 

Effective March 1, 2019, AIM will provide health services review for prior authorization (PA) of physical therapy, occupational therapy and speech therapy for members enrolled in Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect.

 

This transition of utilization management services to AIM does not apply to the Franciscan Alliance Accountable Care Organization/St. Francis Health Network (or other delegated partners). Applied behavioral analysis (ABA) therapy remains covered for the treatment of autism spectrum disorder (ASD) for members 20 years of age and younger. ABA therapy services require PA, subject to the criteria outlined in Indiana Administrative Code 405 IAC 5-3. ABA requests will remain at the health plan. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services will also remain at the health plan.

 

As a reminder, outpatient therapy services currently require PA. Initial evaluations will not require PA, however, providers will be required to request authorizations for all services beginning with the first treatment visit.

 

AIM will continue to use Anthem clinical guidelines CG.REHAB.04, CG.REHAB.05, and CG.REHAB.06 for review of these services. The clinical guidelines can be reviewed on the Medical Policies and Clinical UM Guidelines Search tool located on the Anthem provider website at https://www11.anthem.com/search.html. You can also review them within Availity by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.

 

AIM peer-to-peer

If a peer-to-peer review is needed, AIM will contact the provider prior to rendering a denial. Three attempts will be made by AIM to complete the peer-to-peer review. If AIM is unsuccessful in reaching the provider, a denial decision will be rendered.

 

AIM reconsideration

AIM will accept reconsideration review requests via phone at 1-800-714-0040 or via the AIM portal up to 10 business days from the denial decision date. AIM will render the reconsideration decision and send the notification letter within seven business days.

 

Pre-service review requirements

Beginning February 11, 2019, providers will be able to contact AIM for prior authorization for services to take place on or after March 1, 2019. Providers are strongly encouraged to verify that a prior authorization has been obtained before scheduling and performing services.

 

Any authorizations approved through Anthem prior to March 1, 2019, will be honored and claims will process accordingly. For example, if a provider received an authorization for services starting on February 1, 2019, and the services will extend beyond March 1, 2019, the provider does not need to request a new authorization for services rendered after March 1, 2019.

 

How to place a review request

Providers can utilize the Prior Authorization Lookup Tool (PLUTO) located on the Anthem provider website at https://mediproviders.anthem.com/in/Pages/precertification-lookup.aspx to determine if a specific code requires prior authorization. PLUTO allows the user to search by CPT code, HCPCS code or code description.

 

Providers must utilize the AIM portal or call AIM directly to initiate a new request. The AIM ProviderPortalSM is available 24/7 except for scheduled maintenance and is the fastest, easiest way to contact AIM. The ProviderPortal offers a convenient way to enter your service requests or check the status of your previous services. Go to www.aimspecialtyhealth.com/goweb to begin. Registration is required and opens February 11, 2019.

 

To request prior authorization for outpatient therapy services, please follow this process:

  • Log in to the AIM portal at https://providerportal.com or access the AIM portal via Availity at https://www.availity.com.
  • Providers may contact AIM toll-free at 1-800-714-0040. Hours of operation are Monday through Friday from 8 a.m. to 8 p.m. Eastern time.
  • Fax requests are not accepted for initial services reviewed by AIM.

 

While PA procedures for musculoskeletal services have changed as noted above, certain core services and capabilities — while subject to future changes, independent of AIM’s role in musculoskeletal services PA — remain unchanged at this time, including:

  • Claims processing
  • The network of providers offering these services to our members

 

Please note that adhering to these new policies and procedures is required to assure appropriate payment of claims. Should you have questions, please contact your local Network Relations representative. You may also contact Provider Services at the following numbers:

  • Hoosier Healthwise: 1-866-408-6132
  • Healthy Indiana Plan: 1-844-533-1995
  • Hoosier Care Connect: 1-844-284-1798

 

For resources to help your practice get started with the Rehabilitation Program, go to www.aimprovider.com/rehabilitation.

 


www.anthem.com/inmedicaiddoc

Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.

 



Featured In:
February 2019 Anthem Indiana Provider Newsletter