Musculoskeletal Program - Providers Portal · For the Musculoskeletal program, we have a variety of spine surgeons affiliated with AIM to drive the most appropriate use of spine procedures

Musculoskeletal ProgramInterventional Pain Management Joint Surgery

3/25/2019

1 © 2019 AIM Specialty Health® All Rights Reserved.

Today’s agenda


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


Program specifics


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


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


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


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


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


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


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


Accessing ProviderPortal




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



Hover over Authorization & Notifications then come to Prior Authorization Procedure Code Lookup to see status of the code(s)



Review the tool instructions, then scroll down



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



To review the Musculoskeletal/Joint/Pain landing page hover over Authorizations & Notifications come down to the link



Review the data and select Launch to start your authorization



Below the Launch button are the tools to assist you with the program

Provider Portal Demo



ProviderPortal process

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Spine surgery, interventional

pain management or joint

surgery



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If member has other orders,

they will show up in the

member history.



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If the requesting and servicing

provider are the same, answer

yes to copy the provider

information



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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)


© 2019 AIM Specialty Health® All rights reserved45


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.



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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



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


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…


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


Provider microsite overview


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?


Documents

Musculoskeletal Program - Providers Portal · For the Musculoskeletal program, we have a variety of spine surgeons affiliated with AIM to drive the most appropriate use of spine procedures