Surgical Clinical Site of Care review updates

Members enrolled in Empire BlueCross BlueShield (“Empire”) commercial plans require a medical necessity review of the site of care for numerous surgical procedures performed in an outpatient hospital setting with dates of service on or after January 1, 2021. Clinical guideline CG-SURG-52, Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services will apply to the review process. AIM Specialty Health_® (AIM) will administer the review.

 

Providers are encouraged to obtain privileges at a non-hospital-based facility.   To allow sufficient time for providers to obtain privileges at a non-hospital-based facility, providers may attest to lack of privileges when requesting a prior authorization. Please note that effective September 1, 2021, an outpatient hospital department will only be approved when medical necessity is met to use a hospital site of service. 

 

If you have questions around which participating ASCs are nearest to your location, please email us at ASCPrivilegingSupport@anthem.com

 

For additional information, please refer the October Newsletter.

 

The site of care review only applies to outpatient procedures performed in a hospital-based facility.   The site of care review does not apply to outpatient procedures performed in a non-hospital-based facility or as part of an inpatient stay, nor when Empire is the secondary payer.

 

For a complete list of procedures included in this site of care review, Frequently Asked Question and additional information, visit aimproviders.com/surgicalprocedures/resources. 

 

Providers should always use the Empire assigned member ID number and continue to verify eligibility and benefits for all members prior to rendering services.

 

The AIM reviews apply to local fully insured Empire members and any member covered under self-insured (ASO) benefit plans with services medically managed by AIM; to include the City of NY.

 

They do not apply to BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®) or ASO benefit plans where services are not medically managed by AIM.  Providers can view specific guidelines and prior authorization requirements for Empire members on the Prior Authorization page of our empireblue.com/provider. 

 

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

 

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