Medicare Advantage Outpatient Rehabilitation Program transition information
Effective April 1, 2020, Empire BlueCross (Empire) will transition the utilization management of our Medicare Advantage Outpatient Rehabilitation Program from American Specialty Health (ASH) to AIM Specialty Health® (AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Program includes physical, occupational and speech therapy services. Empire has an existing relationship with AIM in the administration of other programs.
This transition enables Empire to expand and optimize this program further, ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Empire for medical necessity determination. For Medicare Advantage, Empire makes coverage determinations based on guidance from CMS, including national coverage determinations, local coverage determinations, other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.
AIM will continue to use criteria documented in Empire’s clinical guidelines CG.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://www.availity.com by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.
Detailed prior authorization requirements are available online at https://www.availity.com by accessing the Precertification Lookup Tool under Payer Spaces. Contracted and noncontracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.
Prior authorization review requirements
For outpatient rehabilitation services scheduled to be rendered through March 31, 2020, contact ASH. Any authorizations ASH makes prior to the transition date of April 1, 2020, will be honored, and claims will process accordingly.
For services that are scheduled on or after April 1, 2020, contact AIM to obtain prior authorization. Beginning March 16, 2020, you can start contacting AIM for prior authorization on services to take place on or after April 1, 2020. We strongly encourage that you verify you have obtained prior authorization before scheduling and performing services.
How to place a review request
You can make a review request online via the AIM ProviderPortalSM. This service is available 24/7 to process requests in real time using clinical criteria. Go to https://www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 8 a.m. to 8 p.m. Eastern time.
For more information
For resources to help your practice get started with the Outpatient Rehabilitation Program, go to https://aimproviders.com/rehabilitation.
Visit the provider website (www.empireblue.com/medicareprovider) for additional information and tools, such as an FAQ, order entry checklists and clinical guidelines.
February 2020 Empire Provider News