Frequently Asked Questions

What is the Rehabilitation Program? How does it benefit health plan members?
The AIM Specialty Health® (AIM) Rehabilitation Program is here to support you in helping your patients receive the care that is appropriate, safe, and affordable. Through impactful communication and education about the program, we are poised to engage you and your office support staff in the management of the complexities associated with physical, occupational, and speech therapy services. We have developed an approach that works with you to:

  • Promote standard of care through the consistent use of evidence-based criteria
  • Direct care to the most clinically appropriate setting
  • Offer unique consumer education and engagement that facilitates shared decision-making and activates patient involvement through online resources

Your patients’ health plan is implementing the program to help you in your efforts to ensure your patients receive care that is appropriate, safe, and affordable – and delivers improved results for your practice too.

Asking the right questions leads to delivering the right answers at the right time to your patients.

How will the program be administered?
The Rehabilitation Program will be administered by AIM on behalf of your patients’ health plan. Participating in the program is most easily managed using the AIM ProviderPortalSM, available 24 hours a day, 7 days a week.

What is the relationship between AIM and the health plan?
The health plan has contracted with AIM to work directly with you to assist your efforts in patient care. We help you manage physical, occupational, and speech therapy services.

Who is AIM?
AIM Specialty Health is a leading specialty benefits management company with more than 25 years of experience and a growing presence in the management of radiology, cardiology, genetic testing, oncology, musculoskeletal, sleep management, and additional specialty areas. Our mission is to help ensure health care services are more clinically appropriate, safer, and more affordable. We promote the most appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services.

Our Rehabilitation clinical guidelines were developed by a clinical team led by a physiatrist and therapists.

How does AIM work with health plans?
AIM collaborates with health plans to help improve health care quality and manage costs for some of today’s complex tests and treatments, working with physicians like you to promote patient care that’s appropriate, safe, and affordable. In partnership with health plans, we are fully committed to achieving their goals – and yours – to improve health outcomes and reduce costs. Our powerful specialty benefits platform powers evidence-based clinical solutions that span the specialized clinical categories where a health plan has chosen to focus. Our robust medical necessity review process is fully compliant with regulatory and accrediting organizations, while offering a superior experience for you and the health plan’s providers.

Does Anthem require a prior authorization for physical, occupational and speech therapy services?

Yes, prior authorization is required for physical, occupational and speech therapy services.  Treatment codes and re-evaluation codes will require a utilization management (UM) prior authorization review through AIM.

Does Anthem cover medically necessary telehealth (audio and video) for physical, occupational, and speech therapy for all lines of business?

Yes.  Certain CPT codes would be appropriate to consider for telehealth (audio and video) for physical, occupational, and speech therapies.  For 90 days effective March 17, 2020, Anthem will waive member cost shares for telehealth visits for the following physical, occupational and speech therapies for visits coded with Place of Service (POS) “02” and modifier 95 or GT:

  • Physical therapy (PT) evaluation codes 97161, 97162, 97163 and 97164
  • Occupational (OT) therapy evaluation codes 97165, 97166, 97167 and 97168
  • PT/OT treatment codes 97110, 97112, 97530 and 97535
  • Speech therapy (ST) evaluation codes 92521, 92522, 92523 and 92524
  • Speech therapy treatment codes 92507, 92526, 92606 and 92609

PT/OT codes that require equipment and/or direct physical hands-on interaction and therefore are not appropriate via telehealth include: 97010-97028, 97032-97039, 97113-97124, 97139-97150, 97533 and 97537-97546.

Limitation related to state mandates and licensure/state practice act would still apply.

Benefit limitations, where applicable, would still apply.

This 90 day procedural modification applies to all lines of business.

For the latest Anthem COVID-19 information, please check your Anthem.com market website often

How does the Rehabilitation Program work? 

Through our program, we are here to assist you and other participating providers. You contact AIM to request a review of physical, occupational, and speech therapy services. We review for these services in outpatient settings against evidence-based clinical guidelines to ensure care is medically necessary according to medical evidence.

When the care requested does not meet clinical criteria, our established staff of therapists and physicians provide peer-to-peer consultation.

Our program takes individual clinical details into account in order to titrate the number of authorized visits as opposed to program models that approve a standard number of visits upfront. We measure progress based on condition management and patient outcomes. Additional visits are approved as clinically appropriate.

Unlike models that offer a one-size-fits-all approach, our program reviews based on multiple clinical factors.

Are your clinical criteria available for review?
Yes, the AIM Clinical Guidelines are easily accessible online. See Clinical Guidelines. You can also find these within the AIM ProviderPortal, when clinical review requests are initiated.

Tools for patient success

Engaging your patients in their health is a priority for your practice. Our Rehabilitation Program supports your efforts to reinforce important information about the therapy services you recommend. This program is designed to reduce anxiety, drive adherence to care plans, motivate preventive action, and improve appropriate use of care by your patients.

How do I participate in the Rehabilitation Program through AIM?
The best way to submit a therapy service request is to use the AIM ProviderPortal.

ProviderPortal allows you to open a new order, update an existing order, and retrieve your order summary. As an online application, ProviderPortal is available 24/7. Your first step is to register your practice in ProviderPortal, if you are not already registered. Go to www.providerportal.com to register.

If you have previously registered for other services managed by AIM (diagnostic imaging, radiation therapy), there is no need to register again.

Is registration required at AIM ProviderPortalSM?
Each member of your staff who enters review requests will need to register.
Here’s how to do it:

  • Step one: Go to www.ProviderPortal.com and select “Register Now” to launch the registration wizard
  • Step two: Enter user details and select user role as “Ordering Provider
  • Step three: Create user name and password
  • Step four: Enter the tax ID numbers for your providers
  • Step five: Check your inbox for an email from AIM. Click on the link to confirm email address

The AIM ProviderPortal support team will then contact the user to finalize the registration process.

What do I need to register?

  • Your email address
  • The Tax ID number for the providers whose orders you will be entering
  • Your phone and fax number

The AIM ProviderPortal allows you to:

  • Submit a new order request
  • Update an existing one
  • Retrieve your order summary

Which procedures require review?
Contact AIM to obtain pre-service review for the following non-emergency modalities:

  • Physical therapy
  • Occupational therapy
  • Speech therapy

CPT Codes
See the billing codes for the procedures we review
Note: procedures reviewed may vary by health plan.

What providers are included in this program?
The AIM Rehab Program follows the Anthem Clinical Guidelines that states that skilled services may be delivered by a licensed physical therapist or other licensed health care professional (CG-Rehab-04). Qualified providers acting within the scope of their license, including chiropractors, who intend to provide the CPT codes referenced in this Clinical Guideline should request pre-authorization for those services through AIM. AIM has the appropriate staff necessary to satisfy the KY and VA same state licensure requirements, if necessary, for chiropractic reviews.

AIM and Anthem will evaluate the current provider data file to determine if any additional provider specialty codes are required for Rehab.

How does AIM make alternate site-of-care recommendations?
Preferred facilities are identified by your patient’s health plan.

Does the program include inpatient services?
No, the program does not include inpatient services. Only services requested on outpatient basis are applicable to this program.

What information do I need to submit to AIM?
Our order request checklists show exactly what information you will need.

How do I use the AIM ProviderPortal to submit my treatment?
Once registered, log in to the ProviderPortal to begin the order entry process. You will be guided through a series of questions regarding your patient, the requested procedure, and your patient’s clinical condition.

What happens if I do not call AIM or enter information through the AIM ProviderPortal?
You have up to two business days from the service date to obtain a pre-authorization from AIM.

When will I receive the determination?
If the necessary information is provided, determinations are immediate in most cases. Refer to the order request checklists to view the information needed to enter a request.

How will I know if my request met clinical criteria and was approved?
If the information provided meets the clinical criteria an order number, the number of approved visits and authorization timeframe will be issued.

How long does my patient’s approval last?
Unless otherwise required by state law, physical therapy, occupational therapy and speech-language therapy valid timeframe will be based on the number of visits allocated for the service. AIM communicates the valid timeframe in the approval notification for each case.

Can an authorization number for a medical necessity determination expire?
Yes, AIM communicates the expiration date in the approval notification provided for each case.

What if my request indicates “further review is required”?
Review the list of options specified, if it indicates that documents are required, go to the document  upload section and upload the specified documents. Otherwise, if all criteria are not met or review is needed, your request is forwarded to an appropriate therapist (i.e., physical, occupational or speech) or registered nurse (RN) who uses additional clinical experience and knowledge to evaluate the request against clinical guidelines. The clinical reviewer has the authority to issue order numbers in the event it is determined that the request meets clinical criteria.

If an order number could not be issued by the clinical reviewer, an AIM physician will review the request. The physician reviewer can approve the case based on a review of information collected or through their discussion with the provider. At any time, you may contact AIM to discuss the request or to provide additional information.

In the event that the AIM physician reviewer cannot approve the case based on the information previously collected or on the information supplied by you during a peer-to-peer discussion, the physician reviewer will issue a denial for the request.

How do I obtain my pre-authorization results?
When registering for a portal login, specify the email address where notifications should be sent. Once a determination is made on your request, you will receive an email containing a link to the results.

What are my options if a review request does not meet clinical criteria?
Your office can contact AIM to request a peer-to-peer discussion at any time before or after the determination. When there is a request for a peer-to-peer consultation, we will make an effort to transfer the call immediately to an available AIM clinical reviewer. When a clinical reviewer is not available, we will offer a scheduled call back time that is convenient for the practice

If you receive notice of a denial, you have two options for further review. One is to ask for a reconsideration of the decision within 10 days of the denial. This gives the provider an opportunity to provide additional information to one of our clinical reviewers who will have the authority to overturn the denial if clinical criteria is met. The second option is to file an appeal to the health plan, information on how to file an appeal can be found in the letter.

Is Autism in scope?
Anthem and AIM Specialty Health are working together to make improvements to the clinical review of PT/OT/ST Services when used to treat Autism Spectrum Disorder or Pervasive Developmental Delays as defined by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.

For commercial fully insured membership in the states of Georgia, Indiana, Kentucky, Missouri, Ohio, Wisconsin, Connecticut, New Hampshire, New York, Maine, Nevada, and Colorado preauthorization is not required for PT, OT, or ST out-patient therapy services with a confirmed diagnosis of Autism Spectrum Disorder or Pervasive Developmental Delays. You may file your claims without a preauthorization number if you are billing with one of the following ICD-10 codes: F84.0, F84.2, F84.3, F84.5, F84.8, or F84.9. Please note that benefit limits, if applicable, will still be applied.

Note:  for the Medicaid states of Indiana, New York, Western New York, and Wisconsin, there are no changes to the existing program.

Is the initial treatment included in the evaluation authorization for the first visit?

The initial evaluation does not require pre-authorization.  Commercial fully insured members do not require a pre-auth for treatment rendered with the evaluation. However, Medicaid and Medicare members require an authorization for any treatment rendered with the evaluation.  Medicare and Medicaid providers have two options:

  1. Providers can come to the portal, prior to the initial evaluation and answer the question, “has an initial evaluation been performed, “no” and receive an immediate 1 visit allocation.  The provider would then return to portal prior to the first subsequent treatment visit to submit a pre-authorization request.
  2. Providers can perform the initial evaluation and treatment and then come to the portal within 2 business days of the initial evaluation to submit a request for authorization.  In this example, the initial evaluation date and the start date of treatment would both be the same (the initial evaluation date).

When answering the question about an evaluation being conducted for this treatment episode, would it apply if another therapist in my office completed the evaluation?
Yes, it would apply to anyone in your billing facility that completed the evaluation and had developed a plan of care that a qualified provider would follow.

What if the functional tool that I utilize on a patient is not listed in your selection box?
There is an option to enter “tool not listed”, and a text box allowing you to enter the name of the functional tool that you utilized. Note that our clinical decision trees are based on the most common functional tools utilized in the therapy industry.

What if I utilize more than one functional tool for a complex patient case?
There is an opportunity to enter more than one functional tool on a request noting that the patient is being treated for more than one body part. This would enable an allocation of the appropriate number of visits considering both functional tools.

What if the patient has multiple diagnoses relevant to their treatment episode?
Please enter the most relevant treatment diagnosis that is the reason the patient requires skilled therapy services. If care is completed for one diagnosis and you are continuing care for another diagnosis, you will have the ability to reflect a more complex clinical situation that will determine appropriateness of continued care.

Can a patient receive treatment for more than one discipline (PT, OT, ST) at the same time under your program?
Yes, you would request and receive a separate authorization for your patient for each of the disciplines if they meet medical necessity. Each authorization would have a separate order number and a distinct valid time frame. Each discipline would decrement to the patient’s annual benefit level for that service, for example the PT authorization would be considered against the patient’s annual PT benefit limit. If a patient has a combined service limit, the authorization would be matched against the consolidated benefit limit on a first come, first served basis.

Why do I have to attest to the fact that services will be delivered by a licensed provider of therapy services?
Health plan and AIM clinical guidelines require that services meet medical necessity criteria when they are delivered under the supervision of a licensed clinician to perform those services. They are part of a complete plan of care that includes measurable, functional, and objective goals that can reasonably be attained in a predictable period of time, and require the skills of a licensed provider of therapy services.

What if I want more visits than the current authorization includes?
The number of visits authorized is based on your patient’s individual clinical circumstances. However, our program model allows you to render the appropriate visits and see how your patient responds to therapy. Once those visits have been delivered, you have the opportunity to re-enter the portal and report the patient’s improvement and get additional visits approved if clinically appropriate.

Where can I access additional information?
For more information: Our dedicated Rehabilitation Solution provider website offers you all the tools and information you need. To access, go to www.aimproviders.com/rehabilitation/.

What do providers need to take into consideration when submitting a Medicare Advantage AIM Rehabilitation request?

Per CMS, Chiropractors are not in scope as ordering and servicing providers for Rehabilitation services included in this program.

The initial evaluation code does not require authorization, but any treatment service codes will require authorization if performed at the initial evaluation. Providers have two options:

  1. Providers can come to the portal, prior to the initial evaluation and answer the question, “has an initial evaluation been performed, “no” and receive an immediate 1 visit allocation.  The provider would then return to portal prior to the first subsequent treatment visit to submit a pre-authorization request.
  2. Providers can perform the initial evaluation and treatment and then come to the portal within 2 business days of the initial evaluation to submit a request for authorization.  In this example, the initial evaluation date and the start date of treatment would both be the same (the initial evaluation date).

The following Physical Therapy and Occupational Therapy CPT codes are required to be entered individually on a request, if applicable to the treatment plan, as coverage determinations may vary:

  • 97024 – Application of heat wave therapy to 1 or more areas
  • 97026 – Application of low energy heat (infrared) to 1 or more areas
  • 97032 – Application of electrical stimulation to 1 or more areas, each 15 minutes
  • 97033 – Application of medication through skin using electrical current, each 15 minutes
  • 97035 – Application of ultrasound to 1 or more areas, each 15 minutes

The basis of the Rehabilitation program clinical appropriateness reviews include the appropriate National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Medicare Benefit Policy Manual Chapter 15, Section 220 and 230, along with Anthem Clinical Guidelines: CG-Rehab-04 Physical Therapy, CG-Rehab-05 Occupational Therapy and CG‑Rehab‑06 Speech Therapy.