Enforcement of preauthorization requirements for outpatient hospital procedures takes effect Jan. 1, 2015

As we announced in the August Record, effective Jan. 1, 2015, services requiring preauthorization in the hospital outpatient and ambulatory surgical facility locations will be denied when preauthorization is not obtained by the ordering physician.

Rejections will affect all components of service (global, technical and professional). And members cannot be billed for these denied services.

These changes apply specifically to members enrolled in our Radiology Management Program, inclusive of echocardiography procedures and future implemented preauthorization programs. Future programs include the In-lab Sleep Studies Program, which will be implemented Feb. 1, 2015.

To avoid claims rejections, hospitals should always verify that preauthorization was obtained for services performed in the outpatient setting prior to scheduling the procedure. Once enforcement is implemented, quarterly hospital compliance letters that are currently issued to hospitals will be discontinued.

Services performed as the result of emergency, urgent or observation care — or taking place in the labor room — do not require preauthorization. In these instances, the professional component of the service must be billed with the emergency services or ET modifier so that the preauthorization requirement will be waived.

To verify that a preauthorization was obtained, you can contact AIM one of two ways:

• Access AIM’s online ProviderPortal (aimspecialtyhealth.com/goweb**), which is available 24 hours a day, seven days a week. Providers can register at aimspecialtyhealth.com/goweb**. If you have questions about the registration process, call AIM’s Web Help Desk at 1-800-252-2021.
• Call AIM toll-free at 1-800-728-8008, Monday through Friday from 8 a.m. to 5 p.m., to submit a request or verify that an order number has been issued.

If you have questions about these changes, refer to your provider manual, available on web-DENIS, or contact your provider consultant.

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