Site of Care medical necessity reviews for a wide range of surgical procedures beginning January 1, 2021
Members enrolled in Empire commercial plans will require a medical necessity review of the site of care* for numerous surgical procedures performed in an outpatient hospital setting with dates of service on or after January 1, 2021. 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 included in this site of care review, 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 Empire is the secondary payer.
Submit a request for review to AIM
Starting December 23, 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 January 1, 2021 to AIM in one of the following ways:
- Access AIM’s ProviderPortalSM at 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 com.
- Call the AIM Contact Center toll-free at 877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
Beginning in December, AIM will offer webinars to provide information on navigating the AIM ProviderPortal. To register for a webinar visit aimproviders.com/surgical procedures.
This review applies to local fully insured Empire members and members covered under self-insured (ASO) benefit plans with services medically managed by AIM. They do not apply to BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®). Providers can view specific guidelines and prior authorization requirements for Empire members on the Prior Authorization page of our empireblue.com/provider.
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 member’s 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, Empire will hereafter use “site of care”.
October 2020 Empire Provider News