Site of care medical necessity reviews expands to numerous surgical procedures beginning December 1, 2020*

Anthem Blue Cross and Blue Shield (Anthem) is committed to being a valued health care partner in identifying ways to achieve better health outcomes, lower costs and deliver access to a better health care experience for consumers.

 

For members enrolled in Anthem commercial plans with dates of service on or after December 1, 2020, the site of care medical necessity review will expand to numerous surgical procedures performed in an outpatient hospital setting. Clinical guideline CG-SURG-52, Site of Care**: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services will apply to the review process. AIM Specialty Health_® (AIM) will administer the review.

 

The site of care review will apply to a wide range of surgical procedures, including but not limited to, the following specialty categories:

• Auditory system
• Digestive/Gastrointestinal system
• Eye/ocular adnexa system
• Female genital system
• Hemic and lymphatic system
• Integumentary system
• Male genital system
• Musculoskeletal system
• Nervous system
• Respiratory system
• Urinary system

 

For a complete list of procedures, Frequently Asked Question and additional information, visit aimproviders.com/surgicalprocedures/resources. 

 

AIM will use CG-SURG-52 to evaluate the clinical information in the request and determine if the procedure requested requires a hospital-based outpatient setting. Providers may contact AIM to request a peer-to-peer discussion before or after the review is complete.

 

The site of care review only applies to procedures performed in an outpatient hospital setting. The site of care review does not apply to procedures performed in a non-hospital setting or as part of an inpatient stay, nor when Anthem is the secondary payer.

 

Submit a request for review to AIM

Starting November 16, 2020, ordering providers may submit prior authorization requests for the hospital outpatient site of care for the applicable procedures for dates of service on or after December 1, 2020 to AIM in one of the following ways:

• Access AIM’s ProviderPortal_SM 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 at 800-554-0580, Monday through Friday, 8:30 a.m.to 7:00 p.m. ET.

Beginning in November, AIM will offer webinars to provide information on navigating the AIM ProviderPortal. To register for a webinar visit aimproviders.com/surgicalprocedures. 

 

This review applies to local fully insured Anthem members and members covered under self-insured (ASO) benefit plans with services medically managed by AIM. This review does not apply to BlueCard^®, Medicare Advantage, Medicaid, Medicare Supplement, or Federal Employee Program^® (FEP^®).  Providers can view specific guidelines and prior authorization requirements for members on the Prior Authorization page of our anthem.com provider website.

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the back of the members’ ID card.

 

* In some plans, ”level of care,” “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts, or other materials instead of or in addition to “site of care” and, in some plans, these terms may be used interchangeably. For simplicity, Anthem will hereafter use “site of care”.

** At the time of this notice, Anthem is in the process of retitling this guideline to use Site of Care in place of Level of Care.

 

622-0920-PN-CNT