Effective October 1, 2019, Anthem Blue Cross and Blue Shield (Anthem) will transition utilization management of our Outpatient Rehabilitation Program for Medicare Advantage from OrthoNet LLC to AIM Specialty Health® (AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Program includes physical, occupational and speech therapy services. Anthem has an existing relationship with AIM in the administration of other programs.


This transition enables Anthem to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Anthem for medical necessity determination. For Medicare Advantage, Anthem makes coverage determinations based on guidance from CMS including national coverage determinations (NCDs), local coverage determinations (LCDs), other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.


AIM will continue to use criteria documented in Anthem clinical guidelines GC.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://www.availity.com by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.


Detailed prior authorization requirements are available online by accessing the Precertification Lookup Tool under Payer Spaces at https://www.availity.com. Contracted and non-contracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.


Prior authorization review requirements

For services scheduled to be rendered through September 30, 2019, providers must contact OrthoNet LLC to obtain prior authorizations for outpatient rehabilitation services. Any authorizations OrthoNet LLC makes prior to the transition date of October 1, 2019, will be honored and claims will process accordingly.


For services that are scheduled on or after October 1, 2019, providers must contact AIM to obtain prior authorization. Beginning September 15, 2019, providers will be able to contact AIM for prior authorization on services to take place on or after October 1, 2019. Providers are strongly encouraged to verify that they have obtained prior authorization before scheduling and performing services.


How to place a review request

You may place a request online via the AIM ProviderPortalSM. This service is available 24/7 to process requests in real time using clinical criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 7 a.m. to 7 p.m. Central time.


For more information

For resources to help your practice get started with the Outpatient Rehabilitation Program, go to www.aimproviders.com/rehabilitation. Our provider website helps you learn more and provides access to useful information and tools such as order entry checklists, clinical guidelines and FAQ.




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July 2019 Anthem Provider News - Ohio