musculoskeletal program - providers portal · for the musculoskeletal program, we have a variety of...
TRANSCRIPT
Musculoskeletal ProgramInterventional Pain Management Joint Surgery
3/25/2019
1 © 2019 AIM Specialty Health® All Rights Reserved.
Today’s agenda
2 © 2019 AIM Specialty Health® All Rights Reserved.
Agenda
AIM overview
How the program works
Accessing ProviderPortalSM
Demonstration of joint and pain request process
Blue Cross of Idaho program elements
Q & A
AIM overview
3 © 2019 AIM Specialty Health® All rights reserved.
Who is AIM Specialty Health®?
AIM Specialty Health (AIM) is a leading specialty benefits management company who partners with Blue Cross of
Idaho (BCI) on a variety of clinical appropriateness review programs that promote the standard of care. Our innovative
and physician-centric experience fueled by our dedicated people, efficient process, and user-friendly tools creates
value for health plans across the country.
Advanced Imaging
Sleep Medicine
MusculoskeletalSpine (Pain and
Joint New for 2019)
© 2019 AIM Specialty Health® All rights reserved
Our nationally recognized team of clinical leaders ensures credibility in our approach to each solution
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STACEY
BAN
Medical Director,
Oncology
Programs
CHRIS
BUCKLE
Medical Director,
Radiology
VARSHA
CHANDRAMOULI
Vice President,
Clinical Operations
JENNIFER
ECKLUND
Associate
Medical Director,
Government
Programs
MICHAEL J.
FISCH
Medical Director,
Medical Oncology
Programs and
Genetics
WILLIAM ROBERT
MARTIN III
Medical Director,
Musculoskeletal
THOMAS P.
POWER
Senior
Medical Director,
Cardiology and
Sleep Medicine
KERRIE
REED
Medical Director,
Rehabilitation
RICHARD
VALDESUSO
Senior Medical
Director,
Musculoskeletal
ROBERT
ZIMMERMAN
Medical Director,
Radiation Oncology
ROBERT
FURNO
Medical Director,
Government
Programs
(Medicare)
RAHUL
DHAWAN
Associate Medical
Director, Government
Programs (Medicaid)
and Nephrology
ROBERT
MANDEL
Senior
Vice President and
Chief Medical Officer
JULIE
THIEL
Senior
Vice President,
Clinical Programs
How the program works
6 © 2019 AIM Specialty Health® All rights reserved.
Program specifics
7 © 2018 AIM Specialty Health® All Rights Reserved.
April 1st, 2019PROGRAM LAUNCH DATE
March 25th,
2019CALL CENTER OPEN DATE
IMPORTANT
DATES
Commercial &
Medicare AdvantageCOVERED
MEMBERSHIP
Interventional Pain
Joint SurgeryCLINICAL
DOMAIN
~5minsAVERAGE TIME TO
INITIATE A CASE ONLINE
© 2019 AIM Specialty Health® All rights reserved
What’s different from current health plan program?
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Interventional Pain 3 Days
IMPROVED TURNAROUND TIME FOR PAIN AND
JOINT SURGERY REQUESTS WITH AIM
Specialty Matched
MD ReviewersINTERVENTIONAL PAIN SPECIALISTS AND JOINT
SURGEONS AVAILABLE FOR PEER TO PEER
DISCUSSIONS
Review Enhancements
Joint Surgery
Multidisciplinary team supports our program
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(3+ clinic days per month)
Neuroradiology
Leveraging the clinical experience
from our core Radiology program,
our deep clinical expertise creates
tremendous value
for a comprehensive spine
and interventional pain
management program.
Neuro & Orthopedic
SpineFor the Musculoskeletal
program, we have
a variety of spine surgeons
affiliated with AIM to drive
the most appropriate use of
spine procedures.
Anesthesiology
To promote the standards of care
for interventional pain management,
our clinical bench includes board-
certified anesthesiology resources
who guide the development of
evidence-based guidelines
Orthopedic
Joint & Sports
MedicineClinical subject matter experts in
this domain provide guideline support
and consulting on prevailing practices
across the country. AIM incorporates
physician feedback from the leading
professional societies
to encourage quality care
More than 30%
of AIM clinical
team members
maintain an
active practice
Physical medicine
and rehabilitation Knowing the specialty integration
necessary with spine and pain
management procedures, the AIM
comprehensive program includes
subject matter experts in
physical medicine
© 2019 AIM Specialty Health® All rights reserved
Clinical review workflow
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Standard pre-service clinical review steps
Pre-service
reconsiderations
Pre-service provider
document review
1st level provider appeals
managed by AIM
5Additional reviewoptions
Document final review
outcome
Messaging of final review
outcome to provider
Denial and approval letter
generation
Extract case information to
health plan
4Caseclosure
Messaging on
appropriateness of request
and link to guidelines
Peer-to-peer discussion if
previous adjudication
indicated that case is
inappropriate
3Education andintervention
Clinical appropriateness
adjudication against AIM
guidelines
Clinical appropriateness
adjudication against health
plan medical policy
2Caseadjudication
Member demographics
Requesting provider and
facility demographics
Clinical case information
Document upload
(if applicable)
1Caseintake
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Order request check list
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Date of the procedure and type of facility
(i.e. inpatient, outpatient hospital, office, or
ambulatory surgery center)
Requested procedure laterality
(right, left, or bilateral)
Spine levels and region (if applicable)
Co-morbidities or surgical risk factors
(if applicable)
Anticipated need for a co-surgeon, assistant
surgeon, or surgical assistant
(if applicable)
Various documentation supporting medical
necessity
Member first and last name
and date of birth
Order provider first and last name
CPT code(s) and the name of the
procedure you are requesting
Demographicinformation
Clinicalinformation
Refer to the AIM MSK microsite for more
details: http://aimproviders.com/msk
© 2019 AIM Specialty Health® All rights reserved
Program scope
• Epidural Injections (Interlaminar/Caudal and Transforaminal)
• Facet Joint Injections/ Medial Branch Blocks
• Facet Joint Radiofrequency Nerve Ablation
• Implanted Spinal Cord Stimulators
• Regional Sympathetic Blocks
• Sacroiliac Joint Injections
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Procedures included in the program
• Total Hip Replacement
• Total Knee Replacement
• Shoulder Arthroplasty
• Hip Arthroscopy
• Knee Arthroscopy
• Shoulder Arthroscopy
Interventional pain management Joint surgery
© 2019 AIM Specialty Health® All rights reserved
Clinical appropriateness review - Pain
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Included settings:
• Frequency of injections
• Results of prior injections
• Duration of therapy
Interventional pain management
• Longitudinal record and the capture of
previous procedure history
• Conservative Treatment
• Ambulatory surgical center
• Outpatient hospital
• Physician’s office
© 2019 AIM Specialty Health® All rights reserved
Clinical appropriateness review - Joints
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Included settings:
• Level of pain
• Level of function
• Imaging report
Total joint and arthroscopy
• Conservative treatment
• Smoking cessation
• Weight reduction to achieve a BMI <40
• Ambulatory surgical center
• Inpatient hospital
• Outpatient hospital
© 2019 AIM Specialty Health® All rights reserved
Accessing ProviderPortal
15 © 2019 AIM Specialty Health® All rights reserved.
Accessing ProviderPortalSM
16 © 2018 AIM Specialty Health® All Rights Reserved.
Blue Cross of Idaho’s portal for physicians continues to be the gateway into the AIM online initiation tool. Log in to access.
Entry
of
User
Info
Accessing ProviderPortalSM
17 © 2018 AIM Specialty Health® All Rights Reserved.
Hover over Authorization & Notifications then come to Prior Authorization Procedure Code Lookup to see status of the code(s)
Accessing ProviderPortalSM
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Review the tool instructions, then scroll down
Accessing ProviderPortalSM
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Enter the patient information, then Search. When patient is found then select Enter Procedure Code. Enter all codes for the
episode and dates of service. Select Search then results will display. If an authorization is needed select the hyperlink in the
text to go to enter the authorization.
*The results could tell you the
code doesn’t require an
authorization or point you to the
correct system to complete the
authorization.
Last name
Last name, first name
Birth Date: 01/01/1970
Enrollee ID: IDxxxxxxxxx
Enrollment Status: Active
01/01/1970
Accessing ProviderPortalSM
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To review the Musculoskeletal/Joint/Pain landing page hover over Authorizations & Notifications come down to the link
Accessing ProviderPortalSM
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Review the data and select Launch to start your authorization
Accessing ProviderPortalSM
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Below the Launch button are the tools to assist you with the program
Provider Portal Demo
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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Spine surgery, interventional
pain management or joint
surgery
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ProviderPortal process
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If member has other orders,
they will show up in the
member history.
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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If the requesting and servicing
provider are the same, answer
yes to copy the provider
information
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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ProviderPortal process
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© 2019 AIM Specialty Health® All rights reserved
ProviderPortal process
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If no additional clinical review is
needed, the summary page will
show the authorization number for
the request.
Part II: Provider documentation review (PDR)
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© 2019 AIM Specialty Health® All rights reserved45
ProviderPortal process
The provider
documentation review
allows you to provide
additional clinical
information not previously
submitted for a denied
case if the request is
received within 10
calendar days of the date
of determination for
commercial members.
On portal, search for the
order and select the non-
authorized case.
© 2019 AIM Specialty Health® All rights reserved
ProviderPortal process
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Attaching the additional
information to the case
triggers the provider
documentation review to
begin.
Closed case will be
reopened for further
review using the
additional information.
BC IdahoProgram elements
47 © 2019 AIM Specialty Health® All rights reserved.
© 2019 AIM Specialty Health® All rights reserved
Submitting an order request
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Dedicated toll-free number: 1-866-714-1105
Dedicated clinical navigator line: (224) 278-5110
Contact center hours: Mon – Fri, 8am to 6pm MDT
Voice mail received after business hours will be responded to the next business day
Access AIM ProviderPortal through Blue Cross of Idaho Portal
Available 24 hours/day, 7 days/week(except for maintenance on Sundays from 12-6 p.m. CST)
ProviderPortal Support Team can be reached through the below toll free number
AIM Clinical Guidelines available on ProviderPortal
* AIM call center is closed on the following holidays: Thanksgiving Day, Day after Thanksgiving, Christmas Day,
New Year’s Day, Martin Luther King Jr. Day, Memorial Day, Independence Day, and Labor Day.
ProviderPortal
AIM Contact Center
How long is a case valid?
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ORDER NUMBER EXPIRES: ORDER NUMBER EXPIRES:
6 30MONTHS CALENDAR DAYS
from the date the case was created from the date of service
Joint Surgery Interventional Pain Management
© 2019 AIM Specialty Health® All rights reserved
Time period of review process
• Prospective reviews
• ≤7 calendar day retrospective review
• Reconsiderations for Commercial cases up to 10
calendar days with additional information.
• 1st level provider appeals for Commercial cases up
to 180 days from date of service
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• Emergent (ER) requests
• Concurrent stay reviews
• >7 day retro review
will perform… will perform…
© 2019 AIM Specialty Health® All rights reserved
Program start date
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Contact Center and ProviderPortal opens Program Go–Live
252019 2019
MARCH
01APRIL
Contact center and ProviderPortal will be available beginning on 3/25/2019 for preauthorization
requests with dates of service rendered on or after 4/1/2019
Reference Materials
52 © 2019 AIM Specialty Health® All rights reserved.
Provider microsite overview
53 © 2019 AIM Specialty Health® All Rights Reserved.
Comprehensive Provider Microsite
• On-site clinical engagement
• Clinical guidelines
• Worksheets and checklists
• FAQs
• Webinars
www.aimproviders.com/msk/
Clinical reference materials
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AIM provides a myriad of tools to help facilitate a positive physician experience
© 2018 AIM Specialty Health® All Rights Reserved.
Questions?
55 © 2019 AIM Specialty Health® All rights reserved.