Outpatient Rehabilitation Program transition: New prior authorization requirements
Effective April 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will transition the utilization management of our Outpatient Rehabilitation Program 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 relationship with AIM will enable 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. Anthem makes coverage determinations based on guidance from CMS, including national coverage determinations, local coverage determinations, 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 CG.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://medicalpolicies.amerigroup.com/am_search.html.
Detailed prior authorization requirements are available online https://www.availity.com by accessing the Precertification Lookup Tool under Payer Spaces. Contracted and noncontracted 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 to be rendered for dates of service from October 1, 2019, through March 31, 2020, no prior authorization is required for outpatient rehabilitation services. For these service dates, in addition to all other rights Anthem has under our provider contract and law, Anthem and AIM will continue to monitor claims history and utilization trends and will validate provider and member information.
AIM will facilitate training sessions to provide an overview of the program and demonstrate the AIM ProviderPortalSM. Please access the AIM Rehabilitation Provider Portal to register for an upcoming session.
For services that are scheduled on or after April 1, 2020, providers must contact AIM to obtain prior authorization. Beginning March 19, 2020, providers will be able to contact AIM for prior authorization of services to take place on or after April 1, 2020. 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 prior authorization request online via the AIM ProviderPortal. 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 through 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. For portal login Issues, call 1-800-252-2021.
The AIM website provides access to useful information and tools, such as order entry checklists, clinical guidelines and a FAQ.
March 2020 Anthem Provider News - Virginia