Effective January 2, 2018, AmeriHealth is introducing a new Musculoskeletal Utilization Management Program, which will review certain treatment plans for precertification based on a medical necessity review. Precertification for these services will be delegated to AIM Specialty Health^® (AIM) for all AmeriHealth members. AIM will use appropriate AmeriHealth medical policies or AIM Clinical Appropriateness Guidelines to help ensure that care aligns with established evidence-based medicine. In addition, these services will be reviewed for appropriate inpatient and outpatient setting and site of service.

Precertification requirements

For surgeries that are scheduled to begin on or after January 2, 2018, providers must contact AIM to request precertification for the following non-emergency modalities:

• Spinal surgical procedures. Cervical, thoracic, lumbar, and sacral (including all concurrent spinal procedures and all associated revision surgeries):
  • – Cervical Decompression With or Without Fusion
  • – Cervical Disc Arthroplasty
  • – Lumbar Disc Arthroplasty
  • – Lumbar Discectomy, Foraminotomy, and Laminotomy
  • – Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)
  • – Lumbar Laminectomy
  • – Noninvasive Electrical Bone Growth Stimulation
  • – Vertebroplasty/Kyphoplasty
  • – Bone Graft Substitutes and Bone Morphogenetic Proteins
• Surgical procedures of the joint. Including all associated revision surgeries:
  • – Shoulder Arthroplasty
  • – Shoulder Arthroscopy and Open Procedures
  • – Hip Arthroplasty
  • – Hip Arthroscopy and Open Procedures
  • – Knee Arthroplasty
  • – Knee Arthroscopy and Open Procedures
  • – Meniscal Allograft Transplantation of the Knee
  • – Treatment of Osteochondral Defects

Submitting requests to AIM

Ordering or performing providers can submit precertification requests for these services using AIM's ProviderPortal^SM, which providers can access directly through AIM's website or through the NaviNet^® web portal by selecting Authorizations from the Workflows menu and then AIM. Starting December 18, 2017, providers can begin submitting precertification requests to AIM for dates of service on or after January 2, 2018.

Note: When submitting precertification requests for musculoskeletal services, you will be prompted to answer additional questions related to the setting/site of the requested services.

AIM's ProviderPortal is available seven days a week and offers providers the following:

• easy-to-use interface for efficient precertification requests;
• printable precertification summary information sheets for completed requests;
• online tracking of previous precertification requests and status of open requests.

If there is a discrepancy between the procedure to be performed and the procedure that received precertification, the performing provider should consult with both the ordering provider and AIM to address the discrepancy and request any necessary changes to the authorization before rendering service.

Policies and guidelines

For more information, please refer to Medical Policy #00.01.66: Musculoskeletal Services, which is currently posted as a Notification and will go into effect January 2, 2018. The medical policy includes the specific AmeriHealth medical policies and a link to Clinical Appropriateness Guidelines that AIM will use during the precertification process, as well as a listing of procedure codes requiring precertification.

To view the Notification for this medical policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial under Active Notifications.

More information

For questions about this new 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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