This FAQ was revised on March 13, 2023, to reflect the change from AIM Specialty Health® to Carelon Medical Benefits Management.
The following frequently asked questions (FAQ) were developed to provide more detailed information about the AmeriHealth Musculoskeletal Utilization Management Program. This program reviews treatment plans for select non-emergency musculoskeletal services, including spine, joint, and interventional pain management, against clinical appropriateness criteria to help ensure that care aligns with established evidence-based medicine for all AmeriHealth members. Precertification for these services is delegated to Carelon Medical Benefits Management (Carelon), a specialty benefits management company. Carelon reviews procedures using evidence-based Clinical Appropriate Guidelines to ensure care is medically necessary per criteria put forth by the American Academy of Orthopedic Surgeons. Carelon will also review precertification requests for non-emergency musculoskeletal services to be sure they are being directed to the most clinically appropriate setting, as well as level of care (i.e., inpatient vs. outpatient) for spine and select joint services.
Note: This document will be updated as additional information becomes available.
1. Why did AmeriHealth implement a Musculoskeletal Utilization Management Program?
After thorough internal review of the musculoskeletal spine, joint, and interventional pain management services our members currently receive, as well as nationally available data, AmeriHealth made the decision to implement a Musculoskeletal Utilization Management Program to ensure members receive care that is appropriate, safe, and affordable. Precertification for select musculoskeletal spine, joint, and interventional pain management services is delegated to Carelon for all AmeriHealth members. Carelon will review precertification requests using evidence-based Clinical Appropriateness Guidelines to ensure care is medically necessary according to criteria put forth by the American Academy of Orthopedic Surgeons.
2. When did AmeriHealth implement the new Musculoskeletal Utilization Management Program?
Please note the following effective dates:
- Precertification for spine and joint services was delegated to Carelon for dates of service on or after January 2, 2018. Carelon will also review these services to be sure they are being directed to the most clinically appropriate setting, as well as level of care (i.e., inpatient vs. outpatient) for spine and select joint services.
- Precertification for interventional pain management services was delegated to Carelon for dates of service on or after March 1, 2018. Carelon will also review these services to be sure they are being directed to the most clinically appropriate setting.
3. What is the Musculoskeletal Utilization Management Program and how does it benefit health plan members?
The Musculoskeletal Utilization Management Program is intended to ensure that AmeriHealth members receive care that is appropriate, safe, and affordable. Carelon is poised to engage physicians and their office support staff in the management of the complexities associated with spine, joint, and interventional pain management services. Carelon has developed an approach to:
- promote standard of care through the consistent use of evidence-based criteria;
- direct care to the most clinically appropriate setting;
- direct care for spine and select joint services to the most appropriate level of care (i.e., inpatient vs. outpatient);
- facilitate shared decision-making and activate patient involvement through online resources.
4. How is the program administered?
AmeriHealth has delegated precertification for the Musculoskeletal Utilization Management Program to Carelon. In addition, Carelon will review musculoskeletal spine, joint, and interventional pain management services for appropriate setting, as well as spine and select joint services for appropriate level of care (i.e., inpatient vs. outpatient).
5. Which musculoskeletal services are included in the Musculoskeletal Utilization Management Program?
AmeriHealth created Medical Policy #00.01.66: Musculoskeletal Services to detail the new precertification requirements for the following services and delegation of this responsibility to Carelon:
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Surgical procedures of the spine. 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
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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
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Interventional pain management procedures. Including the following:
- – Epidural injections
- – Facet joint injections/medial branch blocks
- – Facet joint radiofrequency nerve ablation
- – Sacroiliac joint injections
- – Implanted spinal cord stimulators
Note: Acute fractures or trauma and neurological conditions that present in the emergency room do not require precertification.
6. Which providers are affected by these requirements?
Providers who are seeking precertification for AmeriHealth members for musculoskeletal spine, joint, and interventional pain management services that are part of the Musculoskeletal Utilization Management Program are affected by these requirements. This includes any providers who, within the scope of their license, can perform these services, including, but not limited to, orthopedic surgeons and anesthesiologists.
7. How were providers notified about the requirements included in the Musculoskeletal Utilization Management Program?
On October 3, 2017, a new medical policy was announced to providers regarding the spine and joint portion of the new program. On December 1, 2017, an updated policy was announced to providers regarding the addition of the interventional pain management portion to the program. The new policy was announced via:
8. How can a provider submit a precertification request to Carelon?
Ordering or performing providers can submit precertification to Carelon in one of the following ways:
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PEAR Practice Management.* From the Transactions menu, select Carelon from the Authorizations section.
- Carelon ProviderPortalSM. Go to https://providerportal.com.
The Carelon ProviderPortal is available 24/7 and allows you to open a new order, update an existing order, and retrieve your order summary. Your first step is to register your practice for the ProviderPortal if you are not already registered. Go to https://providerportal.com to register.
Note: If you have previously registered for other services managed by Carelon (diagnostic imaging, radiation therapy, specialty drugs), there is no need to register again.
9. How does the Musculoskeletal Utilization Management Program work?
Precertification for the listed musculoskeletal services should be requested through Carelon. Carelon will review the procedures to ensure care is medically necessary per AmeriHealth policies and Carelon's evidence-based Clinical Appropriateness Guidelines criteria, which are leveraged from:
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Spine/joint: American Academy of Orthopedic Surgeons and Milliman clinical guidelines.
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Interventional pain management: American Society of Interventional Pain Physicians, American Society of Anesthesiologists, American Association of Neurological Surgeons, and American Pain Society clinical guidelines.
The following AmeriHealth policies are applicable to determine medical necessity for the following procedures/services:
Spine:
- #05.00.09: Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
- #11.14.10: Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
- #11.14.19: Artificial Intervertebral Disc Insertion
- #11.14.27: Spinal Fusion
- #11.14.28: Spinal Laminectomy
- #11.14.29: Spinal Discectomy
- #12.01.01: Experimental/Investigational Services
Joint:
- #11.14.03: Meniscal Allograft Transplantation
- #11.14.06: Autologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
- #11.14.09: Osteochondral Autograft Transplantation (OAT) Procedure
- #11.14.12: Osteochondral Allograft Transplantation
- #11.14.23: Surgical Treatment of Femoroacetabular Impingement
- #12.01.01: Experimental/Investigational Services
Interventional pain management:
- #08.00.57: Complex Regional Pain Syndrome (CRPS) Parenteral Treatments
- #11.15.01: Spinal Cord and Dorsal Root Ganglion Stimulation
- #11.15.09: Denervation of the Spinal Nerves for Chronic Pain
- #11.15.23: Epidural, Paravertebral Facet, and Sacroiliac Joint Injections for Spinal Pain Management
- #12.01.01: Experimental/Investigational Services
When the care requested does not meet clinical criteria, Carelon's established staff of orthopedic surgeons, neurosurgeons, and other specialists provide peer-to-peer consultation to the requesting provider.
Carelon will also review the setting and level of care (i.e., inpatient vs. outpatient - for spine and select joint services only) requested to ensure it's appropriate for the patient's procedure based on his or her specific clinical circumstances.
10. What happens if the procedures billed are not those that have been authorized?
Prior to performing a service, providers should review the procedure codes and descriptions that have been authorized. If the procedures billed are not those that have been authorized, or within the same procedure code grouping of the codes that have been authorized, the service will be denied appropriately for “no authorization on file."
If there is a discrepancy between the procedure to be performed and the procedure that was preauthorized/preapproved, the provider (performing and/or ordering) should work with Carelon to address the discrepancy and request any necessary changes to the authorization before rendering the service.
In cases where a different or additional service was determined to be necessary during the time of the procedure, the provider has 48 hours post-procedure to submit an update to the authorization.
11. How can I review the Clinical Appropriateness Guidelines used by Carelon?
AmeriHealth Medical Policy #00.01.66: Musculoskeletal Services includes a link to the Carelon Clinical Appropriateness Guidelines.In addition, providers can find the Carelon Clinical Appropriateness Guidelines on the Carelon website and request a copy of the guidelines from Carelon by calling them toll-free at 1-800-252-2021, Monday - Friday, 8:00 a.m. - 6:30 p.m. EST.
12. What kinds of cases are reviewed for setting and level of care?
Carelon will review spine, joint, and interventional pain management services for appropriate setting against evidence-based Clinical Appropriateness Guidelines to help reduce inappropriate care, overutilization, and excessive costs, while helping to ensure appropriate, safe, and affordable care. Carelon will also review spine and select joint services for level of care (i.e., inpatient vs. outpatient).
Carelon's established staff of orthopedic surgeons, neurosurgeons, and other specialists provide peer-to-peer engagement to the requesting provider.
13. Does the program include inpatient services?
The program includes all procedures noted in question 5, regardless of whether they are performed in an inpatient or outpatient level of care.
14. Are providers offered a dispute resolution process?
Yes, providers are offered the standard dispute resolution process as detailed in the Clinical Services ? Utilization Management section of the
Provider Manual for Participating Professional Providers.
For more information
Please refer to the Medical and Claim Payment Policy Portal to view the most recent version of these medical
policies, as they will supersede the information in this FAQ.
*Additional information and self-service training materials for the PEAR Practice Management application on the Provider Engagement, Analytics & Reporting (PEAR) portal are available in the PEAR Help Center.
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