Frequently Asked Questions

What is the Surgical Procedures Program? How does it benefit health plan members?
This Surgical Procedures review is here to help support you in helping your patients receive care that is appropriate, safe, and affordable. It promotes services that align with the standard of care through the consistent use of evidence-based criteria.

How will the review be administered?
The Surgical Procedures review is administered by AIM Specialty Health® (AIM) on behalf of your patients’ health plan. Participating is most easily managed using the ProviderPortalSM, available 24 hours a day, 7 days a week. 

Who is AIM?
AIM Specialty Health, a separate company, collaborates with payors to help improve health care quality and manage costs for some of today’s complex tests and treatments, promoting care that’s appropriate, safe, and affordable.

What kind of cases are reviewed?
Modalities may vary by health plan. Refer to Resources for more information.

How does the Surgical Procedures review work?
Your practice contacts AIM to request a review of included procedures. You will be asked to submit certain information about your patient and their clinical condition. The information you enter is compared against evidence-based clinical guidelines. If the information provided meets criteria in the applicable clinical guideline(s), an order number will be issued. When the care requested does not meet clinical criteria, our established staff of physicians can provide a peer-to-peer consultation.

For some health plans, the program also includes a member engagement initiative called Specialty Care ShopperSM. When you recommend certain procedures, Specialty Care Shopper offers cost information to your patients about nearby facilities that offer surgical procedures.

Is your clinical criteria available for review?
Yes, our clinical guidelines are easily accessible online. You can find the clinical guidelines that apply to your health plan under Resources. These can also be found within the AIM ProviderPortal, when clinical review requests are initiated.

Which procedures require review?
Treatment of conditions that present in the emergency room or as part of a hospital in-patient stay do not require pre-authorization.

You can find the CPT codes for the procedures that apply to your health plan under Resources.

Does the review include inpatient or observation services or services rendered on an emergency basis?
No. The review includes only elective procedures performed on an outpatient basis (hospital, ambulatory surgery center, or physician office).

How do I participate in the Surgical Procedures review through AIM?
The best way to submit a review request is to use the AIM ProviderPortalSM.

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 hours a day, 7 days a week. 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, etc.), 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 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 order
  • Retrieve your order summary

 

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 information do I need to submit to AIM?

Our simple checklists show exactly what information you will need.

 

What happens if I do not call AIM or enter information through the AIM ProviderPortal?

If you call the health plan directly, you will be directed to the AIM ProviderPortal or to call the AIM contact center.

How will I know if my order request met clinical criteria and was approved?

When you request review of a procedure, a determination will be made based on the information you provide regarding your patient’s specific clinical condition. If the information provided meets clinical guidelines and is consistent with the health plan’s medical policy, an order number will be issued.

If all criteria are not met or additional information or review is needed, the case is forwarded to a registered nurse (RN) who uses additional clinical experience and knowledge to evaluate the request against clinical guidelines. The nurse reviewer has the authority to issue order numbers in the event that he or she is able to ensure that the request is consistent with our clinical criteria and health plan medical policy.

If an order number still cannot be issued by the nurse, they contact you to schedule a peer-to-peer discussion with an AIM physician reviewer (MD). The physician reviewer can approve the case based on a review of information collected or through their discussion with the ordering or performing physician.

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

How long is my order number valid?
Unless otherwise required by state law, order numbers are valid for 60 calendar days. AIM communicates the expiration date in the approval notification for each case.

Can an order number expire?
Yes, AIM communicates the expiration date in the approval notification provided for each case.

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 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 physician reviewer. When a physician reviewer is not available, we will offer a scheduled call back time that is convenient for the practice.

What is the Surgical Clinical Site of Care review? How does it benefit health plan members?
The Surgical Clinical Site of Care review process is intended to support you in helping patients receive care that is appropriate, safe, and affordable. Certain surgical procedures will require prior authorization if performed in an outpatient hospital setting.

In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of service” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use, “site of care”.

How does the Surgical Clinical Site of Care review process work?
When your practice submits a request for authorization and selects a hospital-based outpatient facility as the site of care for certain surgical procedures, you will be prompted to indicate the reason a hospital-based site of care is medically necessary. If a request for hospital-based site of care does not meet medical necessity criteria, the request will not be approved.

Which surgical services are reviewed for clinical site of care?
See Resources for applicable procedures. This review applies for surgical procedures scheduled to be performed in an outpatient hospital setting. Services performed in an inpatient, emergent or observation setting do not require review.

Where can providers find the clinical guideline that will apply to the surgical clinical site of care review?
When applicable, your patient’s health plan can provide clinical guidelines for clinical site of care review. For your convenience we have provided links to these guidelines here.

How will the review be administered?
The Surgical Clinical Site of Care review is administered by AIM Specialty Health on behalf of your patients’ health plan. Participation in the program is most easily managed using the AIM ProviderPortal, available 24 hours a day, 7 days a week.

AIM Specialty Health conducts reviews of certain surgical services against health plan medical policies and clinical guidelines. Review for clinical appropriateness of the site of care will be provided by an AIM physician reviewer if the service is in scope for this site of care review and the outpatient hospital setting is selected. Note for some services, both the surgical service and the site of care must meet the respective clinical criteria in order for an approval to be issued.

If I select an appropriate site of care location when submitting an authorization request, will the request be reviewed for site of care?
If the prescribing physician selects a facility other than an outpatient hospital, clinical review for site of care will not be required.

Alternate Site of Care Locations

Which participating providers’ locations are considered alternates to an outpatient hospital?
Alternate providers may include licensed ambulatory surgical centers (ASCs) or physician office-based suites. Members and providers are encouraged to use the member’s health plan website to identify participating providers in advance of any service.

Patient Information and Impact 

What if the nearest network ambulatory surgery center is a long distance for the patient to travel or does not have equipment for the planned procedure?
Both geographic access and resource availability will be taken into account in the clinical site of care review process. If your patient does not have geographic access to a network, ambulatory surgery center with the necessary resources to perform the procedure, the procedure can be authorized at a network outpatient hospital site of care.

If I do not have privileges at an Ambulatory Surgery Center, what steps can I take?
We encourage providers to review the network ambulatory surgery centers in their area and obtain privileges with those centers that best meet the provider and members’ needs. The clinical guideline provides criteria for review of the clinical appropriateness of the hospital outpatient site of care (location). Physician privileging at alternate sites of care may be taken into consideration during the review. Please be aware that this is managed by each health plan. Some plans may allow a grace period to provide time for physicians to gain privileges at ambulatory surgery centers. See Resources tab for detail.

Whom do I contact if I have questions?
Please contact your local Network Management representative or call the customer service phone number on the back of your patient’s health care identification card.

Specialty Care Shopper, our member engagement initiative, supports your efforts to reinforce important information about the surgeries and treatments you recommend. This initiative is designed to educate members and allow for greater cost transparency.

How it works:
For health plans enrolled in Specialty Care Shopper, members are contacted by telephone and are provided cost information on both the selected facility as well as nearby surgical facilities, based on the order requests you submit.

Members will have an opportunity to note any questions and concerns, which they can discuss with you at their next appointment. This gives you the opportunity to discuss any additional education and information required.