Material Adverse Change (MAC)

                                                                       

We are 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 August 1, 2021, AIM Specialty Health® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity review of the initial evaluation service codes and requested site of service for physical, occupational and speech therapy procedures for Anthem Blue Cross and Blue Shield (Anthem”) fully insured members, as further outlined below. 

 

AIM will continue to manage Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) medical necessity reviews and will require pre-certification for all outpatient facility and office-based rehabilitative and habilitative services.  Prior authorization will now also be required for the initial evaluation service codes, unless otherwise prohibited, to alert the provider of the site of care program and ensure the member is receiving care at the appropriate site of service early in the process.  After the evaluation, ongoing services will be subject to site of care review and require prior authorization.  AIM will use the following Anthem Blue Cross and Blue Shield (“Anthem”) Clinical UM Guidelines: CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. The clinical criteria to be used for these reviews can be found on Anthem’s Clinical UM Guidelines pagePlease note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, members currently in an episode of care at the start of the program, services with diagnosis of autism, and members ages.

 

A complete list of CPT codes requiring prior authorization for the AIM Rehabilitation program is available on the AIM Rehabilitation microsite.  To determine if prior authorization is needed for an Anthem member on or after August 1, 2021, Providers can contact the Anthem Provider Services phone number on the back of the member’s ID card for benefit information.  They will be informed whether the AIM Rehabilitation program applies.  AIM will also have a file upload from the health plan of the in-scope membership and will not provide pre-certification for members who are out of scope.  If providers use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient rehabilitative or habilitative service, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept pre-certification requests for services administered by AIM.)

 

Members included in the new program

All FI members currently participating in the AIM Rehabilitative program are included. Medicaid members will be included in a separate communication. The following groups are excluded:  Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA EGR, Federal Employee Program® (FEP®). 

 

For self-funded (ASO) groups that currently participate in the AIM Rehabilitative program, the program will be offered to self-funded accounts (ASO) to add to their members’ benefit package.

 

For services provided on or after August 1, 2021, ordering and servicing providers may begin contacting AIM beginning July 19th for review.  Providers may submit prior authorization requests to AIM in one of several ways:

  • Access AIM’s ProviderPortallSM 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 at 877-291-0366, Monday–Friday, 7:00 a.m.–5:00 p.m. PT.

 

Initiating a request on AIM’s ProviderPortalSM for PT/OT/ST 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 Rehabilitation Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.

 

AIM Rehabilitation 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 ProviderPortalSMGo to the AIM Rehabilitation microsite to register for an upcoming webinar on June 22nd, July 8th or 27th at 3pm ET. 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.

 

1121-0521-PN-NV

 



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May 2021 Anthem Provider News - Nevada