Effective August 1, 2021, AIM Specialty Health® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity review of the requested site of service for physical, occupational and speech therapy procedures for Anthem fully-insured members. This site of service review will impact providers of therapy services in the following states:
- New Hampshire
Per AIM, pre-certification will be required for all outpatient facility and office-based rehabilitative and habilitative services. Prior authorization is recommended for the initial evaluation service codes, unless otherwise prohibited, to alert the provider of the site of care program and help ensure the member is receiving care at the appropriate site of service early in the process. After the evaluation, ongoing services will be subject to site of care review and require prior authorization, including post service review which may result in a not medically necessary denial of coverage for the site of care. Requests that are not medically necessary at a hospital site may be approved for coverage at a free standing or office-based setting.
AIM will use the following Anthem Clinical UM Guidelines: CG-REHAB-10 Site of Care: Outpatient Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis, members currently in an episode of care at the start of the program, services with diagnosis of autism, and members ages birth to third birthday.
AIM will begin accepting prior authorization requests on July 19, 2021, for services provided on or after August 1, 2021. Prior authorization requests may be submitted via the AIM ProviderPortalSM or by calling 866-714-1107, Monday – Friday, 8:00 a.m. to 5:00 p.m.
Click HERE for the AIM link. Near the top left, just under the tab “Provider Home”, you can select your state.
Filing complaints: Now that the site of service program has been implemented and patient impacts are anticipated, please remember to remind providers to facilitate patient reporting. As this is only being rolled out with commercial plans, ask they file grievances with the state insurance commissioner, employer, payer and if appropriate the state legislator. The templates are found here.