Update: Notice of changes to the AIM Musculoskeletal Program prior authorization requirements and setting determinations*
As you know, AIM Specialty Health® (AIM) administers the musculoskeletal program, which includes the medical necessity review of certain surgeries of the spine and joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care for Commercial fully insured Anthem Blue Cross and Blue Shield (Anthem) members and some ASO groups.
According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures, it is generally appropriate to perform joint codes (CPT codes 27130, 29871, 29892) and four spine codes (CPT codes 22633, 22634, 63265 and 63267) in a hospital outpatient setting. To avoid additional clinical review for these procedures, providers requesting prior authorization, should either choose “hospital observation” admission as the site of service or hospital outpatient department (HOPD). If the provider determines that an inpatient stay is necessary due to post-operative care requirements, they can initiate a concurrent review request for inpatient admission with the health plan by contacting the number on the back of the member ID card.
Total hip arthroplasty (CPT code 27130) is currently reviewed for medical necessity and level of care. Effective October 1, 2020, four spine codes (CPT codes 22633, 22634, 63265 and 63267) and two joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:
- Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
- Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.
Peer-to-peer conversations are available to a provider at any time to discuss the applicable clinical criteria and to provide information about the circumstances of a specific member.
Providers should continue to submit pre-service review requests to AIM using one of the following 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: 800-554-0580, Monday – Friday, 8:30 a.m. – 7:00 p.m. ET.
For questions, please contact the provider number on the back of the member ID card.
July 2020 Anthem Provider News - Wisconsin