*Material Adverse Change (MAC)

 

Effective October 1, 2022, AIM Specialty Health® (AIM), a separate company, will enhance the AIM Musculoskeletal program by adding a Monitored Anesthesia Care for Interventional Pain component to perform medical necessity review of monitored anesthesia, or conscious sedation, when performing certain interventional pain procedures for Anthem Blue Cross and Blue Shield (Anthem) fully insured members, as outlined below. 

 

Prior authorization will now be required for the clinical appropriateness of monitored anesthesia services when the pain management clinician requests monitored anesthesia services in conjunction with interventional pain codes. It is the obligation of the requesting provider to have available the health plan’s determination for the anesthesiologist on the day of the procedure. AIM will use the following Anthem Clinical UM Guideline: CG-Med-78: Anesthesia Services for Interventional Pain Management Procedures. The clinical criteria to be used for these reviews can be found on the Anthem provider portal Clinical UM Guidelines page.

 

Clinical site of care may also be applicable if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center.  AIM will use the following Anthem Clinical UM Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services.

 

If you have a member in a current course of treatment for pain management where we approved without reviewing the monitored anesthesia care (MAC), please identify the member for us at the next request. Please note, this does not apply to procedures performed on an emergent basis.

 

If the prior authorization was not obtained or did not result in authorization, the anesthesiologist may still determine that member requires monitored anesthesia on the day of service. A retrospective review may be requested or a post service claim may be submitted with a clinical record including the pre-anesthesia assessment, the patient’s medical history documenting that patient meets criteria for MAC and a detailed description of the procedure performed in order for AIM to determine coverage for the service as medically necessary.

 

At this time, the codes to be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940. A complete list of CPT codes requiring prior authorization for the AIM Monitored Anesthesia Care for Interventional Pain program is available on the AIM Musculoskeletal microsite. To determine if prior authorization is needed for an Anthem member on or after October 1, 2022, Providers can contact the Anthem Provider Services phone number on the back of the member’s ID card for benefit information. AIM will recognize out of scope membership and will not require prior authorization for such members. If providers use the Interactive Care Reviewer (ICR) tool on the Availity Portal to pre-certify an outpatient musculoskeletal procedure, ICR will produce a message referring the provider to AIM. (Note: 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 package as of October 1, 2022.

 

Prior authorization requirements

For interventional pain procedures that are scheduled to begin on or after October 1, 2022, all providers must contact AIM to obtain prior authorization. The following groups are excluded:  Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP®). 

 

For services provided on or after October 1, 2022, ordering and servicing providers may begin contacting AIM on September 17, 2022 for review. 

 

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: 833-342-1253, Monday through Friday, from 8:30 a.m. to 7:00 p.m. Eastern time

 

Initiating a request on AIM’s ProviderPortalSM and entering all the requested clinical questions will allow you to receive an immediate determination. 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.

 

2771-0622-PN-ALLCSBD



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June 2022 Anthem Provider News - Wisconsin