Anthem’s New Place-of-Service Guidelines for MRI & CT
As of September 1st, Anthem requires a medical necessity review in 9 states for MRI and CT scans performed on an outpatient basis in hospitals. To date, it has been determined that five additional states will be added to the review process in 2018.
In partnership with AIM Specialty Health, Anthem has introduced a policy change which includes level of care reviews to determine if it is medically necessary to perform MRI and CT scans in a hospital setting or if an alternative free-standing imaging center is clinically appropriate.
What constitutes medical necessity?
- The services being provided are only available in the hospital setting; or
- The individual requires an obstetrical observation; or
- The individual is receiving perinatology services; or
- There are no other geographically accessible appropriate alternative sites for the individual to undergo the procedure, including but not limited to the following:
- Moderate or deep sedation or general anesthesia is required for the procedure and a freestanding facility providing such sedation is not available; or
- The equipment for the size of the individual (that is, very small or very large) is not available in a freestanding facility; or
- The individual has a documented diagnosis of claustrophobia requiring open magnetic resonance imaging which is not available in a freestanding facility
How should a hospital request pre-authorization from AIM?
The precertification request should be submitted via the AIM ProviderPortal and will be reviewed by an AIM physician reviewer based on clinical appropriateness and the level of care against health plan clinical criteria. If the request is denied, AIM will identify alternative free-standing imaging locations.
Should you be in one of the effected states, please make sure to update your OptiNet assessment to reflect the correct Place of Service code and Provider Type. For questions or support, call AIM OptiNet Customer Service at 800-252-2021 or click here for more information.
For more information on the Anthem Clinical UM Guidelines click here
For FAQs provided by Anthem, click here
Our team at Alliance Radiology has created four specific solutions for our hospital partners. Please complete the Contact Form to have one of our market development experts get in touch with your team to present and discuss these solutions.