Prior authorization may also be requested by calling the prior authorization phone number listed on the back of the member’s ID card. Providers should complete the Prior authorization Request form. Participating Providers are required to request prior authorization on the member’s behalf in accordance with the member’s evidence of coverage and listed on the UM Website Prior Authorization List failure to do so may result in denial of the provider’s claim and the member cannot be balance billed. Request, Verify or Obtain Prior authorization Medicaid Prior authorization: To obtain prior authorization for services for Medicaid members, please use the form found under prior authorization Requirements on the Medicaid webpage. Prior authorization is required for all inpatient services and select outpatient services.Ģ023 List of Service Categories Requiring Prior Authorizationįor an overview of the prior authorization process and requirements at BCBSNM, refer to Section 10 of the BCBSNM Provider Reference Manual. Furthermore, neither prior authorization nor recommended clinical review (predetermination) guaranty benefits or payment because, for example, member eligibility and benefits are reassessed as of the date of service and the circumstances represented in the request must have been complete and accurate and remain materially the same as of the date of service.Įligibility and Benefits Reminder: Obtain eligibility and benefits first to confirm membership, verify coverage and determine whether or not prior authorization is required. Once requested, prior authorization and recommended clinical review (predetermination) are processed in the same manner including, but not limited to, which reviewers are qualified to approve and deny, timelines, and notices, including appeal rights. The primary difference is that prior authorization is required for certain services whereas the provider has the option of submitting a Recommended Clinical Review (Predetermination) request before services are rendered and informs the provider of situations where a service could be denied based upon medical necessity. Similarities predominate over differences between these two types of preservice review. Provides OptiNet, the industry’s first web-based diagnostic imaging network management tool, to help health plans manage their imaging provider networks using cost and quality metrics, and there are many of the same awards Aim Provider Portal has won over the years.Blue Cross and Blue Shield of New Mexico (BCBSNM) has two types of preservice review to assess benefits and medical necessity: prior authorization and recommended clinical review (predetermination ). Recertification from NCQA and accreditation from URAC in 2006. Received more than 1 million prior authorization requests through the ProviderPortal in 2006. Opens a second operations center in Westchester, Illinois, to complement its operations center in Deerfield, Illinois. Introduces Imasis, the industry’s first fully customizable and fully functioning web-based call center application. This is in addition to the URAC accreditation that they received in 1998. It grew to over 5 million members in 2004 and obtained initial NCQA certification. One can view all the solutions provided by the AIM providers portal at the official portal. Specialty health solutions provided by AIM include surgical solutions, cardiology solutions, genetic testing solutions, medical oncology solutions, musculoskeletal solutions, sleep solutions, and radiology solutions. The AIM provider platform, featuring a sophisticated clinical rules engine developed by Applied Pathways (a subsidiary of AIM), delivers significant cost of care savings across a broad set of clinical domains, including radiology, cardiology, oncology, specialty drugs, sleep medicine, musculoskeletal care, rehabilitation, surgical procedures, and genetic testing. The AIM health plan serves more than 68 million members in 50 states, the District of Columbia, and US territories, ensuring they receive optimal health care through evidence-based clinical guidelines and real-time decision support. Get a response in real-time 24/7 to your advanced imaging requests with ProviderPortalSM.ĪIM Specialty Health delivers specialty healthcare in an appropriate, safe, and affordable manner. If you have a busy practice like yours, you need to provide quality, appropriate care efficiently. The AIM Provider Portal allows you to access AIM Specialty Health quickly and easily.
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