For fully insured Anthem clients
Effective July 1, 2017, all fully insured businesses became part of a new program, AIM Imaging Clinical Site of Care Review. This was presented at the latest broker meetings, however, we wanted to make sure everyone affected was aware of the new program.
With AIM, Anthem will review the clinical criteria to determine if MRI and CT procedures are clinically appropriate in a hospital setting or if an alternative outpatient facility is available within a 30 mile area. If not clinically appropriate, the hospital setting requests will be denied.
All fully insured businesses were rolled to the Imaging Clinical Site of Care Review on July 1, 2017—not at renewal.
Members who are subject to the Imaging Clinical Site of Care Review will know whether the MRI/CT is approved or denied (whether due to medical necessity or site of care) via the pre-certification letter sent after a decision has been made. The redirection information is provided to the requesting provider.
If the member proceeds with having the service performed even after the denial, then based on the plan benefits, either the provider/member would be liable for the cost.
Please see this presentation for more details regarding this program.
Please contact your advisor or a member of your account team if you have any questions about this new program.