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.

 

Effective November 1, 2020, according to the AIM Level of Care guideline, 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 postoperative 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.

 

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 ProviderPortal_SM 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 portal* at availity.com.
• Call the AIM toll-free number at 1-800-714-0040 Monday through Friday, 8:30 a.m. to 7 p.m. ET.

 

If you have questions, please contact Provider Services at 1-855-558-1443.