Updated AIM Musculoskeletal Program effective September 1, 2022: Site of care reviews
Effective September 1, 2022, AIM Specialty Health® (AIM), a separate company, will expand the AIM Musculoskeletal Program to perform medical necessity review of the requested site of service for certain spine, joint and interventional pain procedures for Anthem Blue Cross and Blue Shield’s (Anthem) fully insured members, as outlined below.
AIM will continue to manage the AIM Musculoskeletal program and level of care review. The AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures is used for the level of care review. Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care). AIM will use the following Anthem Clinical UM Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The clinical criteria to be used for these reviews can be found on the Anthem provider portal Coverage Guidelines & Clinical UM Guidelines page. Please note, this does not apply to procedures performed on an emergent basis.
A subset of the AIM Musculoskeletal Program codes will be reviewed for site of care. A complete list of CPT codes requiring prior authorization for the AIM Musculoskeletal site of care program is available on the AIM Musculoskeletal microsite. To determine if prior authorization for the AIM Musculoskeletal Program applies for an Anthem member on or after September 1, 2022, contact the Anthem Provider Services phone number on the back of the member’s ID card. AIM will also have a file from Anthem of the membership for whom the program applies and will not provide prior authorization for members for whom the program does not apply. NOTE: If providers attempt to use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient musculoskeletal case, ICR will produce a message referring the provider to AIM. (ICR cannot accept prior authorization requests for services administered by AIM.)
Members included in the new program
All fully insured members currently participating in the AIM Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the AIM Musculoskeletal Program to add to their members’ benefit packages as of September 1, 2022. Members enrolled in the following are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, Medicare Advantage Group Retiree Solutions (MA GRS), and the Federal Employee Program® (FEP®).
Pre-service review requirements
For services scheduled to begin on or after September 1, 2022, providers must contact AIM to obtain prior authorization. Ordering and servicing providers may begin contacting AIM on August 15, 2022.
Providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM 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 866-789-0158, Monday–Friday, 8 a.m. to 5 p.m. ET.
Initiating a request on AIM’s ProviderPortalSM 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, number of visits and valid time frame. The AIM Musculoskeletal Program microsite on the AIM provider portal helps you learn more and access helpful information and tools such as order entry checklists.
AIM Musculoskeletal 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 ProviderPortalSM. Go to the AIM Musculoskeletal microsite to register for an upcoming webinar. 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.
June 2022 Anthem Provider News - Virginia