Posted in BCBS Empire NY, NY Providers, Training, Updates

Empire BCBS (NY) Changes to AIM Small Joint Surgery Guideline for 2021

Reminder: as of 11/01/2020 IM Specialty Health® (AIM) began administering the AIM Musculoskeletal program to perform medical necessity reviews for certain elective surgeries of the small joints using AIM clinical guidelines for Empire BlueCross BlueShield (“Empire”) fully insured members and some ASO groups.   

Effective 03/14/2021, the following changes will be made to the Small Joint Surgery Guidelines:

  • Clarified requirements for imaging reports.
  • Removed radiographic requirement for confirmation of lesser toe deformities.
  • Ankle arthrodesis and total ankle arthroplasty added as new indications for revision of failed previous reconstructions.
  • Removed total ankle arthroplasty requirements for adjacent joint or inflammatory arthritis.
  • Clarified contraindications only apply to total ankle arthroplasty.

How to request an authorization:

  • Access AIM 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 Portal at availity.com
  • Call the AIM toll-free number at 1-877-430-2288, Monday through Friday 8:30 am – 7 pm ET.

For further questions, please contact the provider number on the back of the member ID card.

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Posted in Insurance, Payer Updates, Training, Updates

Anthem BCBS (NY) Site of Care review for long-acting colony-stimulating factors, 06/01/2021

This policy is for site of care medical necessity review and it only applies to administration performed in an outpatient hospital setting.

This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Empire is the secondary payer.

The medical necessity Review will be performed by AIM Specialty Health® (AIM).

AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Empire’s Medical Policy and Clinical UM Guideline page and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.

The following codes apply to this policy:

To Submit a request for review:

Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:

  • Access AIM 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: 1- 877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.

This review does not apply to the following plans: BlueCard®, Federal Employee Program® (FEP®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Empire members on the Medical Policy & Clinical UM Guidelines page at empireblue.com/provider.

**Note: In some plans “level of care” 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, we will hereafter use “site of care.”**