New pre-service clinical review requirement for EGD services begins November 1, 2018
Beginning with dates of service on and after November 1, 2018, we will expand pre-service clinical review requirements to include upper gastrointestinal (GI) endoscopy, also referred to as esophagogastroduodenoscopy (EGD). AIM Specialty Health® (AIM), a separate company, will administer this EGD review on our behalf.
EGD procedures will be reviewed against clinical guideline CG-MED-59 Upper Gastrointestinal Endoscopy, for clinical appropriateness and to help ensure care aligns with established evidence-based medicine. Please note, procedures performed in an inpatient or observation setting, or on an emergent basis will not be reviewed under CG-MED-59. Note that CG-MED-59 will be available on our anthem.com website prior to its November 1, 2018 adoption.
A complete list of EGD CPT codes requiring precertification is available on the AIM Surgical Procedures website.
Submit a request for review
Starting October 17, 2018, ordering providers may submit precertification requests for dates of service November 1, 2018 and after to AIM in one of the following ways:
- Access AIM’s ProviderPortalSM 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: 866-714-1107, Monday–Friday, 8:00 a.m.–5:00 p.m.
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 pre-certification requirements for local Anthem members at Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements at anthem.com. Providers should continue to verify eligibility and benefits for all members prior to rendering services.
For questions, please contact the Provider Service number on the back of the member’s ID card.
August 2018 Anthem Maine Provider Newsletter