Prior authorizations submitted digitally can reduce denials associated with manual submission errors. The Interactive Care Reviewer (ICR) prior authorization application makes it easy to submit, review, and check authorization status – all in one place.

Learn how by attending our January 2023 ICR webcast.

When:

Tuesday, January 17, 2023

Noon Eastern time

Register here

Learn how to use ICR to:

• Create an authorization request.
• Inquire on a previously submitted authorization.
• Update a case.
• Copy a case.
• View letters associated with a case.
• Request and check the status of an authorization appeal.

Visit the ICR target page to register, access self-service learning, and to view recorded learning sessions. Download ICR user guides and other job aides from the ICR target page too. You can also register from the Provider Learning Hub by selecting the ICR live webinar learning icon.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* Rehabilitative and Habilitative Services Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Rehabilitative and habilitative services — updates by section

• Clarified language about the background of speech-language professionals
• Clarified language about qualified speech-language pathology providers

Speech therapy alternative treatments:

• Clarified language about qualified speech providers
• Definition of blue dye test clarified
• Parkinson Voice Project definition expanded

Physical therapy and occupational therapy adjunctive treatments:

• Added definition of Lee Silverman Voice Treatment BIG — proprietary program of intensive physical and/or occupational therapy of at least one month duration involving large, full-body exercises to improve functional movement and self-care tasks of people with Parkinson’s disease and other neurological conditions. It requires company-certification of providers.
• Added exclusion for Lee Silverman Voice treatment

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM:

• Access AIM’s 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.

If you have questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

As previously communicated in the December 2022 edition of Provider News, AIM Specialty Health_® (AIM)* will apply additional code updates to the AIM Diagnostic Coronary Angiography and Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. That code update expansion has been delayed. The codes listed below will go into effect April 1, 2023, not February 1, 2023, as originally communicated.

Percutaneous coronary intervention:

• Access AIM’s 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.
• Call the AIM Contact Center toll-free number at 800-714-0040, Monday through Friday, from 7 a.m. to 7 p.m. Central

If you have questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after April 1, 2023, the following CPT^® codes will be added to the AIM Specialty Health_®* (AIM) Percutaneous Coronary Intervention Clinical Appropriateness Guidelines.

Percutaneous Coronary Intervention:

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM through AIM’s ProviderPortal_SM directly at www.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.

If you have questions related to the guideline or code updates to the guideline noted above, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* (AIM) Radiation Oncology Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

• Radiation Therapy— Updates by section
  • Gastrointestinal (GI) Cancers — Intensity modulated radiation therapy (IMRT)
  • Removed plan comparison requirement for cholangiocarcinoma, esophageal, gastric, hepatocellular, and pancreatic cancer, because IMRT has become standard of care for curative treatment of these GI malignancies
• Oligometastatic Extracranial Disease— SBRT: stereotactic body radiation therapy (SBRT)
  • Added indication for adrenal metastases as SABR-COMET trial listed this as one of the most common sites treated in that trial
• Prostate Cancer— Brachytherapy:
  • Added indication for high-dose rate monotherapy in low- and intermediate-risk disease
• Image Guidance radiation therapy (IGRT)
  • Added surface-based guidance technique (no change in intent or coding)
  • Added statement that IGRT is not medically necessary to guide superficial radiotherapy for non-melanoma skin cancer (supported by American Society for Radiation Oncology [ASTRO] Clinical Practice Guideline)

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM through the AIM ProviderPortal_SM directly at www.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. 

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you can access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_® (AIM)* Musculoskeletal — Interventional Pain Management Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Interventional pain management — updates by section:

• Epidural steroid injections:
  • For nerve root compression due to herniated disc, specified that the MRI/CT showing this finding must have been done within 18 months instead of 12 months.
• Selective nerve root block:
  • Included a second session for cases requiring evaluation of more than one level.
• Therapeutic intra-articular facet injections:
  • Included criteria for repeat injections in patients who met criteria for an initial injection.
• Conservative management requirements:
  • Aligned definitions with joint surgery, spine surgery, spine, and extremity imaging guidelines.
  • More rigorous definition of the supervised home physical therapy requirement and removed cognitive behavioral therapy as a conservative care modality.
  • Included activity modification and a trial of rest.
• Epidural steroid injections:
  • Specified that only one spinal region may be treated per date of service.
  • For repeat injection, prior injection must have provided improvement for three months instead of three weeks.
• Diagnostic medial branch block:
  • Specified that up to four diagnostic sessions may be done in a rolling 12-month period (previously three).
  • Reduced the number of unilateral levels that may be done in a session from three to two.
• Thermal medial branch radiofrequency neurotomy:
  • Reduced the number of unilateral levels that may be done in a session from three to two.
  • Specified a maximum of two radiofrequency sessions per rolling 12-month period.
• Regional sympathetic nerve block:
  • Specified that procedure must be performed using imaging guidance.
  • Specified that the procedure must be performed unilaterally.
  • Specified a lifetime maximum of six blocks.
  • Removed exclusions that referred to procedures which are no longer performed.

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM:

• Through AIM’s 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.

If you have questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines online.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* Cardiology Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate and affordable healthcare services.

Cardiac Imaging — Updates by section

Stress testing with imaging:

• Suspected coronary artery disease (CAD) without symptoms — Indications removed
• Suspected CAD with symptoms — Indications modified
• Need for testing determined by pretest probability
• Definition of chest pain expanded to include ischemic equivalent pain elsewhere
• Dyspnea included as standalone symptom
• Imaging modality to be selected by the treating physician
• Exercise preferred over pharmacologic testing in patients referred for stress testing with imaging
• Patients with atypical symptoms to undergo non-imaging stress testing (assuming capable of exercise and no precluding resting EKG abnormalities)
• Established CAD without symptoms — Indications removed
• Established CAD with symptoms — Indications removed

CT coronary angiography (CCTA):

• Indications added — Considerable expansion in use for evaluation of CAD (now a first-line modality)
• Indications added — Preoperative testing indications
• Indications added — Abnormal prior testing indications
• Indications removed — Suspected anomalous coronary arteries (basis for suspicion required)

Fractional Flow Reserve from CCTA (FFR-CT):

• Indication modified — 40% to 90% coronary stenosis in symptomatic patient who has failed guideline-directed medical therapy and has undergone CCTA within preceding 90 days

Stress Cardiac MRI:

• Indications added — Considerable expansion in use for evaluation of CAD (now a first-line modality)
• Indications added — Preoperative testing indications
• Indications added — Abnormal prior testing indications

Resting Cardiac MRI:

• Indication added — Fabry disease
• Indications modified — Suspected myocarditis (basis for suspicion required)
• Indications modified — Arrhythmogenic right ventricular dysplasia (ARVD) requirements clarified
• Indications modified — Suspected anomalous coronary arteries (basis for suspicion required)

Resting transthoracic echocardiography (TTE):

• Valvular heart disease — updated frequency of surveillance in patients with prosthetic valves and those who had transcatheter valve replacement/repair; removed requirement of valvular dysfunction for those who had surgical mitral valve repair; removed moderate/severe mitral regurgitation for those who had transcatheter mitral valve repair

Diagnostic Coronary Angiography:

• Indications modified — Clarification that patients with established CAD who have failed GDMT may undergo coronary angiography regardless of how initial diagnosis was made

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM by accessing AIM’s ProviderPortal_SM directly at www.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.

If you have questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for all claims received on and after February 1, 2023, in accordance with the Anthem Blue Cross and Blue Shield (Anthem) reimbursement policy titled Outpatient Facility Revenue Code Billing Requirements — Facility, Anthem will implement additional steps to review claims submitted by facilities that contain revenue codes but do not include corresponding CPT^® or HCPCS codes when required by the National Uniform Billing Committee (NUBC).

Anthem requires that current and valid CPT or HCPCS codes are reported with all revenue codes as specified in the NUBC requirements for outpatient claims. Claim lines that do not meet this requirement will be denied.

If you have questions about this policy, contact your contract manager or Provider Relationship Management account representative.

Effective with dates of service on or after April 1, 2023, the Federal Employee Program^® (FEP) with Anthem Blue Cross and Blue Shield (Anthem) will refer the following procedures for observation stay instead of full inpatient admission. These services will require prior authorization to determine medical necessity prior to rendering the service for Anthem federal employee members. 

For services that are scheduled to begin on or after April 1, 2023, all providers must be aware that for the following procedures, FEP will be approving observation stay versus inpatient stay when medically appropriate:

• Knee arthroplasty (total/partial/revision knee)
• Shoulder arthroplasty (hemi arthroplasty/arthroscopy) 
• Hip arthroplasty (total/partial/revision hip replacement) and hip arthroscopy
• Cervical fusion (anterior)
• Cervical discectomy or microdiscectomy, foraminotomy, and laminotomy
• Lumbar discectomy, foraminotomy, and/or laminotomy
• Small joint surgeries of the foot and ankle 
• Reconstruction midface, LeFort I-III
• Sacral-Iliac fusion 

How to submit a request for review

Starting March 13, 2023, providers can begin submitting requests for review with dates of service on or after April 1, 2023.  

To reach the FEP Utilization Management (UM) department to submit an authorization request, providers may call our department directly, fax a request, or submit a request via Availity Essentials* with clinical information:

• Phone number:800-860-2156
• Fax:800-732-8318
• Chat: To chat with an FEP UM representative, go to: availity.com. Select Payer Spaces, select Federal Employee Plan, and access the chat through Chat with Payer.

We value your participation in our network, as well as the services you provide. We look forward to working with you to help improve the health of our members. 

The Medical Specialty Drug Review team for Anthem Blue Cross and Blue Shield manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. AIM Specialty Health_®* (AIM), a separate company, manages review of specialty pharmacy drugs for oncology.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Including the national drug code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

Clinical Criteria update: Effective January 1, 2023, clinical criteria naming will be changed
from ING-CC-XXXX to CC-XXXX; however, the content within the documents will remain unchanged.

Prior authorization updates

Correction: In the August 2022 edition of Provider News, we published prior authorization updates for the drug Pluvicto (lutetium lu 177 vipivotide tetraxetan). Please be advised that the effective date for this update has been changed:

• Previous effective date: November 1, 2022
• Updated effective date: February 1, 2023

Access our Clinical Criteria to view the complete information for these prior authorization updates.

* Oncology use is managed by AIM.