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.