CurrentAnthemPolicy N/A

Prior Authorizations Required for new Group-Sponsored MA Membership

Defines utilization management and prior authorization requirements that apply to new group-sponsored Medicare Advantage members (alpha prefixes YGZ and MHG) in specified states and lists programs, services, vendors, contacts, and effective dates.

Policy Summary

PayerAnthem

PolicyPrior Authorizations Required for new Group-Sponsored MA Membership

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2018

Next Review Date

Key ActionSubmit prior authorization requests for eligible services for new group-sponsored Medicare Advantage members (alpha prefixes YGZ and MHG) via the listed vendors or fax to 866-959-1537 and/or Availity Provider Self-Service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2alpha prefixes specified (YGZ, MHG)

9+states referenced

multiplevendors listed

2018-01-01effective date

Services Requiring Review or Prior Authorization

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Examples of service groups

Medical oncology (Part B injectable drugs) — CMS-compliant medical necessity determinations; vendor: AIM Specialty Health; effective dates include YGZ and MHG (effective 3/9/18).
Cardiology procedures — post-service prepay medical necessity reviews of selected cardiac procedures including facility and professional cardiac catheterizations and percutaneous coronary interventions (PCIs); vendor: OrthoNet.
Focused claims review — post-service prepayment procedure code reviews of select professional surgical services (examples: orthopedic surgery, plastic surgery, neurosurgery, sports medicine, podiatry, hand surgery, neurology, pain management, ENT, general surgery, dermatology, cardiology, urology); vendor: OrthoNet.
Genetic testing — prior authorization requests to AIM Specialty Health; applicable to listed states with effective dates including YGZ and MHG (effective 3/9/18).
Radiology services — prior authorization requests submitted to AIM Specialty Health; includes OptiNet registration for certain imaging modalities (MR, PET, nuclear medicine, ultrasound, echocardiography).
Rare disease management — targeted disease management services for specified rare conditions (examples: ALS, CIDP, Crohn's disease, cystic fibrosis, dermatomyositis, epilepsy, Gaucher disease, hemophilia, HIV, MS, myasthenia gravis, Parkinson's disease, polymyositis, rheumatoid arthritis, scleroderma, sickle cell disease, systemic lupus); vendor: Accordant Health Services.
Pain management procedures — prior authorization required for services such as epidurals, facet blocks, implantable infusion pumps, spinal cord stimulators; vendor: OrthoNet.
Physical Therapy and Occupational Therapy (outpatient/office/Part B/long-term care) — medical necessity reviews and prior authorization handled by OrthoNet.
Sleep studies — authorization requests submitted to AIM Specialty Health.
Spine procedures — services such as spinal fusion, spinal decompression, vertebro/kyphoplasty require review by OrthoNet.

How to Submit Reviews, Vendors, and Contacts

Prior Authorization

Prior Authorization Required — Overview and Submission Channels

New group‑sponsored Medicare Advantage members with alpha prefixes YGZ and MHG require prior authorization and utilization management for certain services. Submit prior authorization requests and inquiries using the vendor channels listed below. For inpatient and outpatient prior authorizations (unless noted otherwise), fax to 866‑959‑1537 or use the Vendor-specific submission portals/phone numbers. Confirm member benefits via Availity or the number on the back of the member ID card.

Applies to group‑sponsored MA members with prefixes YGZ and MHG (effective dates vary by program)
Use Availity Provider Self‑Service > Authorizations & Referrals > Anthem Medicare Advantage for detailed precertification submissions where supported
Exceptions and effective dates for specific vendors/programs are noted per vendor below

Note

Service‑Specific Prior Authorization Vendors

The following vendors manage service‑specific prior authorization, utilization management, and focused reviews for group‑sponsored Medicare Advantage members. Submit requests to the vendor that corresponds to the service requested.

AIM / AIM Specialty Health (AIM ProviderPortal / Availity): radiology (advanced imaging), sleep studies, radiation oncology, genetic testing, medical oncology Part B drugs, and OptiNet imaging assessments; site: providerportal.com or aimspecialtyhealth.com/goweb
OrthoNet: preauthorization and medical necessity reviews for selected cardiac procedures (cardiac catheterization, PCI), focused claims reviews for select professional surgical services (orthopedics, plastic surgery, neurosurgery, sports medicine, podiatry, hand surgery, neurology, pain management, ENT, general surgery, dermatology, cardiology, urology), pain management procedures, physical therapy and occupational therapy reviews, spine and implantable device procedures
Accordant Health Services: rare disease management programs for select conditions (ALS, CIDP, Crohn's, CF, dermatomyositis, epilepsy, Gaucher, hemophilia, HIV, MS, myasthenia gravis, Parkinson's, polymyositis, rheumatoid arthritis, scleroderma, sickle cell disease, systemic lupus)
Aspire / Rare disease program contacts per vendor where applicable (refer to Accordant for rare disease management)
Vital Decisions and other case‑management vendors where applicable per program communications

Note

Vendor Contact Information (phone, fax, web)

Phone, fax, and web submission channels by vendor. Use the vendor portal or phone/fax below for prior authorization initiation, clinical submission, and inquiries.

AIM / AIM Specialty Health: Web – providerportal.com or aimspecialtyhealth.com/goweb; Phone – 800‑714‑0040; AIM Customer Service – 800‑252‑2021 (M–F 8am–7pm ET)
OptiNet (via AIM): registration required via AIM ProviderPortal; OptiNet assessment and data collection contact through AIM Customer Service and AIM portal
OrthoNet: Phone – 844‑788‑4805; Fax – 844‑788‑4806; PT/OT reviews: Phone – 844‑340‑6418; Fax – 844‑340‑6419; Focused claims review general fax – 866‑951‑2711; Focused claims review general phone – 888‑230‑1346
Accordant Health Services: Phone/Fax – 1‑866‑247‑1150; referral site – referral.accordant.com
Spine and select procedure prior auth (where specified): Phone – 866‑797‑9884; Fax – 800‑959‑1537 (use for some inpatient/outpatient prior auth submissions unless otherwise noted)

Documentation Required

Imaging Registration and Data Collection (OptiNet via AIM)

All participating Medicare Advantage providers who perform imaging services must register for AIM’s OptiNet via the AIM ProviderPortal. OptiNet will collect modality‑specific data (facility qualifications, technician/physician qualifications, accreditation, equipment, and modality details) for ultrasound, MRI, nuclear medicine, PET, and echocardiography. OptiNet assessments were phased in by prefix/effective date as noted below.

OptiNet registration: complete registration in the AIM ProviderPortal (providerportal.com) before performing covered modalities
Modalities assessed: ultrasound (abdominal/retroperitoneum, gynecological, obstetrical), MRI, nuclear medicine, PET, echocardiography — includes facility, technician and physician qualifications, accreditation and equipment information
Phased effective dates: OptiNet effective 5/1/2018 for YGZ and MHG; later effective dates apply for other prefixes (e.g., 7/1/2018 for MBL, ZDX) — check Important Medicare Advantage Updates for changes
Support: AIM Customer Service 800‑252‑2021 (M–F 8am–7pm ET) or AIM portal for OptiNet questions

Key Terms

inv-07: Members with alpha prefixes YGZ and MHG who are new group-sponsored Medicare Advantage enrollees and subject to the listed utilization management requirements

Who this applies toMembers with alpha prefixes YGZ and MHG who are new group-sponsored Medicare Advantage enrollees

Geographic applicabilityApplicable to new group-sponsored MA members in CO, CT, IN, KY, ME, MO, NH, OH, VA, and WI

Effective dateRequirements expanded effective Jan 1, 2018

Scope of requirementsSubject to utilization management and prior authorization requirements for services listed in the policy (many mirror individual MA requirements)

Submission channelsInpatient and outpatient prior authorization requests can be faxed to 866-959-1537; some requirements accessible via Availity Provider Self-Service

inv-08: Aspire program — a care management program providing 24/7 access to care management for advanced illness; members retain their PCPs

Program nameAspire program (advanced illness care management)

DescriptionProvides Medicare Advantage members and caregivers 24/7 access to appropriate care through the Aspire care management team; does not replace care of PCPs or specialists

Member experienceMembers retain their PCPs and specialists and may continue to seek treatment

States of operation (examples)IN, KY, OH, CT

Contact informationIN: (844) 735-3314; KY: (844) 735-1412; OH: (844) 326-3119; CT: (888) 355-3902

OpenPayer

Prior Authorizations Required for new Group-Sponsored MA Membership

Services Requiring Review or Prior Authorization

Precertification / Codes

How to Submit Reviews, Vendors, and Contacts

Key Terms