Medical necessity review for appropriate level of care

Effective since May 1, 2019, certain service requests for Anthem HealthKeepers Plus members require medical necessity review for level of care. This includes requests for certain procedures currently reimbursed in the inpatient setting (for example, services corresponding to codes found on the CMS Inpatient Only [IPO] List).

 

Certain services that have historically been authorized in the acute inpatient setting may be clinically appropriate for an alternate level of care. For example, while codes for services are listed on the CMS IPO List (a list developed for use in Medicare and not Medicaid managed care), the corresponding services may be appropriate for an alternate level of care. When a request is submitted for a service that may be appropriate for a level of care other than acute inpatient, we review the procedure for medical necessity and apply medical necessity criteria to determine if inpatient level of care is medically necessary.

 

To review for appropriate level of care, we use the applicable MCG Care Guidelines, which may include customizations specifically for Anthem HealthKeepers Plus members, applicable Clinical Utilization Management (UM) Guidelines or AIM Specialty Health® (AIM) guidelines. If medically necessary criteria for the procedure are met, the procedure will be approved. If inpatient level of care is requested but medical necessity criteria for acute inpatient care is not met, the request for inpatient level of care will be denied. A modified approval or denial letter will be issued accordingly.

 

Services requiring prior authorization

 

The list of services requiring prior authorization (PA) will be updated as needed. Regardless of whether PA is required, all services must be medically necessary to be covered. To avoid a claim denial based upon medical necessity, we encourage you to review the corresponding medical necessity criteria prior to rendering nonemergent services (even if PA is not required).

 

Please review the Clinical UM Guidelines and Coverage Guidelines on the provider page as well as the AIM guidelines. The specific MCG Care Guidelines used to make a determination can be provided upon request.

 

Providers are responsible for verifying eligibility and benefits for members before providing services. Excluding emergencies, failure to obtain PA for the services and level of care requiring PA may result in a denial of reimbursement.

 

Requesting PA via Interactive Care Reviewer

 

We are pleased to offer Interactive Care Reviewer (ICR), a UM website that allows you to submit PA requests. ICR is accessible via the Availity Portal at no cost to providers. ICR will accept:

 

• Inpatient requests.

• Outpatient requests.

• Medical and surgical requests.

 

Availity is an independent company that administers a secure provider portal on our behalf. We encourage you to use ICR to submit new PA requests and check the status of already submitted PA requests. If you have questions about ICR or the Availity Portal, contact your network representative.

 

Requesting PA via phone

 

To request PA via phone, report a medical inpatient admission or ask questions regarding PA, contact the UM department at 1-800-901-0020.

 

Requesting PA via fax

 

To request PA via fax for:

 

• Inpatient or outpatient services, call 1-800-964-3627.

• Medical pharmacy (for drugs typically administered by a health care professional), call 1-844-512-7022.

• Pharmacy (for drugs typically self-administered), call 1-844-512-7020.

 

What if I need assistance?

 

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.