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.