​​​​​​​​​​AmeriHealth Administrators to offer enhanced utilization management solutions through AIM and eviCore​​

April 7, 2022

This article was revised on April 7, 2022, to update the effective date.

AmeriHealth Administrators will delegate precertification for certain services to AIM Specialty Health® (AIM) and eviCore healthcare (eviCore)​ in the third quarter of 2022. The ordering provider i​s responsible for submitting precertification requests for the applicable services. ​Failure to adhere to the precertification process may result in a bill to your patient.

This policy does not apply to groups who are not a part of the Enhanced Utilization Program. It is important for providers to verify member eligibility and benefits, and to refer to the most current precertification requirement lists on our website.

AIM

Providers should seek precertification from AIM for:

  • cardiology covered modalities
  • high-technology radiology
  • musculoskeletal
    • spine surgery
    • interventional pain management
    • joint surgery
  • sleep studies, continuous positive airway pressure titration studies, and continuous positive airway pressure (CPAP) devices

Cardiology utilization management

Precertification is required for certain cardiovascular tests/diagnostic procedures and certain nonsurgical treatments for obstructive coronary artery disease and is delegated to AIM for evaluation of medical necessity.

High-technology radiology

Precertification is required for high technology radiology services, with the exception of services performed in the emergency room or during an inpatient or observation unit stay and is delegated to AIM for evaluation of medical necessity. 

Musculoskeletal utilization management

Precertification is required for certain surgical procedures of the spine and joint and interventional pain management procedures and is delegated to AIM for evaluation of medical necessity

Sleep studies

Precertification is required for sleep studies in facility settings, CPAP titration studies in facility settings, and CPAP devices and is delegated to AIM for evaluation of medical necessity.

Policies and guidelines

For additional information on this utilization management program, please refer to these policies on our Medical and Claim Payment Policy Portal. Effective July 1, 2022, these policies will be applicable to plans administered by AmeriHealth Administrators.

  • #11.02.27: Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (AmeriHealth)
  • #09.00.46: High-Technology Radiology Services
  • #00.01.66: Musculoskeletal Services (AmeriHealth)
  • #07.03.05: Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies

eviCore

Providers should seek precertification from eviCore for:

  • certain genetic/genomic tests (i.e., nucleic acid testing) and certain molecular analyses
  • radiation therapy

Certain genetic/genomic tests and molecular analyses

Precertification for certain genetic/genomic tests (i.e., nucleic acid testing) is required and is delegated to eviCore for evaluation of medical necessity.

When a request for genetic/genomic testing is received, laboratories must ensure a precertification is on file before rendering services. If precertification is not on file for the member, it is the laboratory's responsibility to submit a request to eviCore.

Radiation therapy

Precertification for nonemergent outpatient radiation therapy services is required and is delegated to eviCore for evaluation of medical necessity. Precertification is not required when radiation therapy is rendered in the inpatient hospital setting.

Policies and guidelines

For additional information on this utilization management program, please refer to these policies on our Medical and Claim Payment Policy Portal. Effective July 1, 2022, these policies will be applicable to plans administered by AmeriHealth Administrators.

Learn more

If you have questions related to services in our utilization programs that require authorization, contact Provider Services at 1-844-352-1706.