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PAP251

Advanced Imaging Pre/Post Service Process


Provider Administrative Policy

Section
General Billing
Policy Date
February 2009
Status/Date
Revised/June 2014
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Advanced Imaging Pre/Post Service Process

Pre Service Appeals

Advanced imaging studies performed in a non-emergent outpatient setting require prior authorization through AIM Specialty Health (AIM) formerly known as American Imaging Management.

Providers must initiate prior authorization requests through Blue Cross of Idaho's provider portal at bcidaho.com. To submit authorization request to AIM Specialty Health, log in using your username and password and select Advanced Imaging from the left navigation, then Login to Advanced Imaging. AIM completes approximately 94% of provider authorization cases within 24-hours of the request.

If AIM does not approve a prior authorization request and a provider wishes to request a reconsideration of that determination, the ordering provider may contact AIM directly to request a re-review. The ordering provider has 180 days from the initial denial determination to request a reconsideration of the pre-service denial. Another AIM physician of like or similar specialty will perform the second review and provide a determination within 14 calendar days of receipt of all information from the provider.

If AIM requires additional information from the provider in order to complete the review, they will send a Lack of Information (LOI) letter to the ordering provider requesting supporting documentation. The provider has five days to provide the requested information. If AIM does not receive the requested information within the five calendar days, they will close the review and the prior authorization denial will stand. AIM will issue a letter of determination.

Beginning September 1, 2014, Revised Provider Reconsideration language:

Provider reconsideration of prior authorization denials

Blue Cross of Idaho offers providers a reconsideration review of a prior authorization denial for insufficient information to determine medical necessity. The denial letter will describe the information needed to complete the medical necessity review. Authorizations that are denied as not medically necessary or investigational based on  medical policy will not be eligible for reconsideration but can be appealed through the member appeal process. A provider cannot exercise appeal rights on behalf of the member without the member's express written authorization. Our determination of the provider's request for reconsideration does not affect the member's appeal rights under his or her policy.

Blue Cross of Idaho does not offer reconsiderations for services or procedures excluded under the member contract.

Reconsideration

If a provider receives a prior authorization denial from AIM Specialty Health due to insufficient information to determine medical necessity, he or she can request reconsideration by submitting a written or faxed request with the requested supportive documentation to Blue Cross of Idaho's Medical Management Department within 60 days of the original authorization denial. Blue Cross of Idaho will issue a reconsideration determination within 14 calendar days of receiving the reconsideration request.

The following provider reconsideration workflow will no longer be in effect after August 31, 2014

Subsequent Reconsideration - If a provider is not satisfied with the initial reconsideration determination, the provider may submit a second written or faxed reconsideration request with additional supportive documentation to Blue Cross of Idaho's Medical Review Department. Blue Cross of Idaho will issue a reconsideration determination within 10 business days of receiving the subsequent reconsideration request.

A provider cannot exercise appeal rights on behalf of the member without the member's express written authorization. Our determination of the provider's request for reconsideration does not affect the member's appeal rights under his or her policy.

Urgent Reviews
AIM will respond to urgent requests within 72 hours.

Beginning August 1, 2014 revised post service - pre-payment claim review

Blue Cross of Idaho providers will have up to seven (7) days past the date of service to request a retrospective authorization through AIM Specialty Health for advanced imaging services. Although seven (7) days is allowed for a post service review, we strongly encourage participating providers to obtain authorization prior to administering services. Blue Cross of Idaho contracts with AIM to manage utilization for high-technology outpatient diagnostic radiology services offered as part of our radiology management program.

AIM only accepts retro-authorization requests by phone at 866-714-1105.

AIM will deny authorization requests attempted more than seven (7) days past the date of service and not review them for medical necessity. Blue Cross of Idaho will also deny the resulting claim for lack of authorization.

Neither AIM of Blue Cross of Idaho will perform medical necessity reviews retrospectively upon provider inquiry or appeal unless the provider presents a compelling circumstance explaining the lack of prior authorization. Possible scenarios include:

  • If a provider is a new Blue Cross of Idaho contractor and has only seen a small volume of Blue Cross of Idaho members.
  • If a provider presents a remittance advice from another insurance carrier demonstrating an assumption that another payer was primary.

The following post service - pre-payment claim review workflow will no longer be in effect after July 31, 2014.

Post service – pre-payment claim review

If a servicing provider fails to check for a prior authorization, but performs the study and bills for the service, the claim will pend for AIM retrospective medical necessity review.

* AIM will request supporting documentation from the ordering provider. If AIM does not receive the documentation within five calendar days, they will deny the review and pending claim as insufficient clinical information to determine medical necessity. 

*AIM extends the privilege of a medical necessity review to those providers who commonly follow prior authorization requirements. If a provider demonstrates consistent patterns of failing to obtain authorizations, AIM may not provide that provider a retrospective medical necessity review and may result in non-payment of the claim.

Post service/post payment provider inquiry

If the servicing provider wishes to appeal the claim denial, please follow the appeals process through Blue Cross of Idaho as stated in PAP236.


Policy History

Date Action Reason
June 2014 Revised Added Definition of Urgent Care, Added revised provider reconsideration language
July 2009 Revised Retrospective review comment added

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