Frequently Asked Questions

Should my practice request authorizations for specialty drugs using the AIM ProviderPortalSM?
Yes. Your practice should submit authorization requests by accessing the AIM ProviderPortal directly (registration required). Online access is available 24/7 to process orders in real-time, and this is the fastest and most convenient way to request authorization.

How does the clinical site of care review process work?
When your practice submits a request for authorization of a specialty drug and selects a hospital-based outpatient facility as the level of care, a list of alternate locations, such as ambulatory infusion suites and home infusion providers will be made available. Medical specialty pharmacy providers will also be listed as an alternate option to supply the infused medication to physician offices who can administer it to the patient.

If an alternate level of care is not selected, you will be prompted to indicate the reason hospital-based level of care is medically necessary. If a request for hospital-based level of care does not meet medical necessity criteria upon review by a physician reviewer, the request will not be approved.

Infusions and injections currently administered in physician offices, ambulatory infusion suites or at home by a home infusion therapy provider are not impacted.

Which drugs will be reviewed for level of care?
Clinical site of care review includes specialty medications covered under the medical benefit that require preauthorization against a medical policy or clinical guideline that are clinically administered for infusions or injections. Medications with an oncology related diagnosis are excluded from the clinical site of care review. The complete list of drugs reviewed for clinical site of care is available here.

Who will perform clinical site of care review to determine if the administration of a specialty drug in an outpatient facility is medically necessary?
AIM Specialty Health conducts reviews of specialty drug utilization against health plan medical policies and clinical guidelines.

Review for clinical appropriateness of the level of care will be provided by an AIM physician reviewer if the specialty drug is included in the program and outpatient facility setting is selected. Note that when the level of care guideline applies to a drug, it is an integral component of the medical necessity review. The specialty medication and the level of care must both meet their respective clinical criteria in order for an approval to be issued.

If I select an alternate level of care location when submitting an authorization request, will the request be reviewed for level of care?
No. If the prescribing physician selects a physician office, ambulatory infusion suite, or home infusion therapy provider, there will not be a clinical site of care review. Only the drug will need to be reviewed for medical necessity.

Where can providers find the clinical guideline that will apply to clinical site of care review?
Your patient’s health plan can provide clinical guidelines for clinical site of care review

What happens if my patient’s authorization is already approved for administration of a specialty drug in an outpatient facility level of care?
Previously approved authorizations will be honored until the current authorization expires. Once the authorization expires, you will need to request a new authorization and will be directed to an alternate level of service unless it is medically necessary for the patient to continue administration of the specialty drug in an outpatient facility setting.

Does the level of care review apply to medications covered under my patient’s pharmacy benefit?
No. Medications provided under the pharmacy benefit are not reviewed for level of care.

Which locations are considered alternatives to an outpatient facility level of care?
Alternate providers include:

  • Physician offices – administration occurring in a physician office (typically, the prescribing provider)
    • Hospital-owned physicians/physician groups that bill for professional services are considered the same as hospital outpatient service departments and are not considered alternate sites
    • Medical specialty pharmacy providers can supply specialty medications to providers electing to administer medication to the patient in the office, when the provider does not supply the medication itself
  • Ambulatory infusion suites – a health care provider that offers intravenous administration, subcutaneous treatments or administered injections on an outpatient basis in a licensed ambulatory infusion suite
  • Home infusion therapy providers – a health care provider that offers intravenous administration, subcutaneous treatments or administered injections in a home setting

How will providers and members be advised of alternate locations for the administration of the specialty drug?
AIM will provide alternate locations to providers when the authorization is requested and reviewed. Alternate location options will also be listed in provider and patient denial letters.

How will alternate locations be identified for a particular patient?
Alternate provider locations are identified specific to the patient’s medication and patient’s home address, based on their zip code. At a minimum, at least two alternate provider locations will be included, with a maximum of three alternate options.

In any scenario, medical specialty pharmacy providers are a potential option to ship to the physician’s office, if the provider is willing to administer the medication in the office.

What if there are less than two alternate providers available to the patient per their specific location?
If there are less than two alternate providers available, the patient will receive a level of care exception in the higher level of care for the duration of the drug authorization.

Will this change reduce my patient’s out-of-pocket cost?
Out-of-pocket cost can vary depending on the patient’s benefit plan. Patients may experience reduced out-of-pocket costs when using an alternate level of care provider.

Are my patients required to change doctors?
No. The clinical guideline reviews the clinical appropriateness of the level of care (location) dispensing and administering the medication, so it does not impact the patient’s relationship with their prescribing doctor. Prescribing doctors should consider discussing the appropriate level of care to administer the specialty drug with their patient.

Who can my patients call to discuss alternate provider locations?
Patients can call their health plan discuss alternate providers.

What are the requirements for provider offices that currently perform infusions or injections in the office, or would like to start providing infusions or injections in the office for their patients?
Please contact your patient’s health plan for requirements.

What are the qualifications a provider must meet to qualify as an Ambulatory Infusion Suite (AIS) or Home Infusion Therapy (HIT) provider?
The provider must be a licensed pharmacy that provides a wide range of services required to safely and effectively administer infusion, nutritional therapies, specialty drugs, and disease state and care management services in an AIS or Home setting. Typical therapies include but are not limited to, antibiotic therapy, total parental nutrition and pain management. The provider must offer supplies and clinical services furnished by an accredited AIS or HIT to individuals under the care of a physician, or other healthcare provider. Such supplies and clinical services are provided in an integrated manner under a plan established and periodically reviewed by the ordering physician or other healthcare provider.

A summary of other minimum contract considerations include the following:

  • Recognized Accreditation for Home Care and Ambulatory Health Care Services
  • Full Medicare and Medicaid participation
  • Licensed pharmacy
  • Certified/licensed nurses
  • Proof of liability insurance of not less than one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate
  • Acceptance of standard reimbursement fee schedule for medication and administrative services

If you believe your office meets the above criteria, you may contact your network management representative to request more detailed contract criteria.