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:
- 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.
- 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/.