October 04, 2017
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement
Effective December 1, 2017, Anthem Blue Cross will implement a new policy restricting outpatient advanced radiologic imaging procedures in the hospital setting. The updated policy, originally scheduled to become effective October 1 but recently delayed, indicates that advanced radiologic imaging procedures in the hospital outpatient department are only considered medically necessary under the following circumstances:
- If services are only available in the hospital setting; or
- The patient requires obstetrical observation; or
- The patient is receiving perinatology services; or
- There are no other geographically accessible appropriate alternative sites to perform the service, including in instances where:
- general anesthesia or moderate or deep sedation is required and unavailable at a freestanding facility; or
- patient size prohibits the use of equipment at a freestanding facility; or
- the patient has documented history of claustrophobia.
Anthem will utilize AIM Specialty Health to administer the clinical appropriateness reviews for all advanced imaging services, including making the determination if an imaging service requires a hospital-based outpatient setting or if a free-standing imaging center will be chosen to perform the service.
The California Medical Association is in the process of evaluating the new policy to better understand how it would affect physician practices and patient care. Additional information and instructions regarding this program can be found at aimproviders.com/radiology.