AmeriHealth has implemented a "soft launch" of the new Musculoskeletal Utilization Management Program that went into effect January 2, 2018, for spine and joint procedures. The goal of the soft launch is to allow providers and their office staff to:
- adapt to the new precertification requirements;
- familiarize themselves with the process for submitting requests to AIM Specialty Health® (AIM) ? either via the AIM ProviderPortalSM or by calling AIM directly;
- learn about the applicable clinical criteria.
The soft launch applies to all precertification requests for spine and joint procedures included in the Musculoskeletal Utilization Management Program submitted for dates of service January 2, 2018, through January 16, 2018. During the soft launch period, if a precertification request does not meet the applicable clinical criteria, services will still be approved and providers will be educated on why the request did not meet the applicable criteria. Please note that precertification requests will continue to be reviewed and denied for administrative reasons, including, but not limited to, a member who has been disenrolled from an AmeriHealth benefit plan or a member whose benefit plan does not cover the requested service.
For Musculoskeletal services being requested for dates of service on or after January 17, 2018, medical necessity denials will be issued if clinical criteria are not met.
Please also note the following important information, which was published on the AmeriHealth NaviNet Plan Central on December 29, 2017:
- Sending additional clinical documentation. Providers can send additional clinical documentation to AIM by fax to 1-844-425-3738.
- Requesting a peer-to-peer review. Providers can request peer-to-peer review by calling 1-866-745-1791.
- Smoking cessation recommendation. The AmeriHealth policy and AIM?s orthopedic surgery guidelines contain recommendations for smoking cessation and confirmatory blood work prior to surgical procedures of the spine and joint. Please note that for most surgical procedures of the spine and joint, these are purely recommendations and failure to comply will not result in a denial. The only exception is for revision rotator cuff repair, where smoking cessation and confirmatory blood work are mandatory.
For more information
For questions about the Musculoskeletal Utilization Management Program, please review our Musculoskeletal Utilization Management Program: Frequently asked questions (FAQ), which can also be found on AmeriHealth NaviNet Plan Central in the Frequently Asked Questions section under Administrative Tools & Resources. Note: The FAQ will be updated as more information becomes available.
If you still have questions after reviewing the FAQ, please send an email to aimumprograms@amerihealth.com.
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