Musculoskeletal (MSK) Management Program Update

Date: 01/17/24

Dear Provider,

All of us at Ambetter of Alabama are committed to the continuous improvement of quality services for our members. With that in mind, Ambetter of Alabama has entered into an expanded partnership with National Imaging Associates, Inc. (NIA)₁, to implement a Musculoskeletal (MSK) Management program.

This MSK program includes prior authorization for non-emergent outpatient and inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Ambetter of Alabama members. The decision to implement this program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

Under terms of the agreement between Ambetter of Alabama and NIA:

• Ambetter of Alabama will oversee the MSK program and continue to be responsible for claims adjudication and medical policies.
• NIA will manage inpatient and outpatient MSK surgeries through the existing contractual relationships with Ambetter of Alabama.

Planned for a March 1, 2024, implementation, this correspondence serves as notice under your Participating Ambetter of Alabama Provider Agreement of changes to the program.

Providers may begin contacting NIA on March 1, 2024, to seek prior authorization for procedures scheduled on or after March 1, 2024.

The following outlines the specific procedures requiring prior authorization.

MSK Surgeries: Prior authorization will be required for the following non-emergent inpatient and outpatient MSK surgeries: hip, knee, shoulder, lumbar and cervical.

Hip

• Revision/Conversion Hip Arthroplasty
• Total Hip Arthroplasty/Resurfacing
• Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincer & labral repair)
• Hip Surgery – Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)

Knee

• Revision Knee Arthroplasty
• Total Knee Arthroplasty (TKA)
• Partial-Unicompartmental Knee Arthroplasty (UKA)
• Knee Manipulation under Anesthesia (MUA)
• Knee Ligament Reconstruction/Repair
• Knee Meniscectomy/Meniscal Repair/Meniscal Transplant
  
• Knee Surgery – Other (includes synovectomy, loose body removal, diagnostic kneearthroscopy, debridement with or without chondroplasty, lateral release/patellarrealignment, articular cartilage restoration)

Shoulder

• Revision Shoulder Arthroplasty
• Total/Reverse Shoulder Arthroplasty or Resurfacing
• Partial Shoulder Arthroplasty/Hemiarthroplasty
• Shoulder Rotator Cuff Repair
• Shoulder Labral Repair
• Frozen Shoulder Repair/Adhesive Capsulitis
• Shoulder Surgery – Other (includes debridement, manipulation, decompression,tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

Lumbar

• Lumbar Microdiscectomy
• Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)
• Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single & MultipleLevels
• Sacroiliac Joint Fusion

Cervical

• Cervical Anterior Decompression with Fusion –Single & Multiple Levels
• Cervical Posterior Decompression with Fusion –Single & Multiple Levels
• Cervical Posterior Decompression (without fusion)
• Cervical Artificial Disc Replacement
• Cervical Anterior Decompression (without fusion)

KEY PROVISIONS:

• It is the responsibility of the ordering physician to obtain prior authorization for all MSKsurgeries managed by NIA.
• NIA does not manage prior authorization for emergency MSK surgery cases that are admittedthrough the emergency room or for MSK surgery procedures outside of those procedures listedabove.
• The ordering physician must obtain prior authorization with NIA prior to performing thesurgery/procedure.
• Facility admissions do not require a separate prior authorization. However, the facility shouldensure that an NIA prior authorization has been obtained prior to scheduling thesurgery/procedure.

MSK surgeries other than those outlined above will continue to follow Ambetter of Alabama priorauthorization requirements for hospital admissions and elective surgeries.

We appreciate your support and look forward to your assistance in assuring that Ambetter of Alabamamembers receive MSK services delivered in a quality, clinically appropriate fashion.

We will provide additional information as we get closer to the implementation date. Should you havequestions, please contact Ambetter of Alabama Provider Services Department at 1-800-442-1623, or email us at AmbetterAL_ProviderRelations@centene.com.

Sincerely,

Ambetter of Alabama Provider Relations

₁Effective 1/20/2023, National Imaging Associates, Inc. is now a subsidiary of Evolent Health. Evolent Health and its affiliates and subsidiaries collectively referred to as “Evolent.”