Musculoskeletal (MSK) Management program

Date: 11/01/23

Ambetter of Illinois (Ambetter) is committed to the continuous improvement of quality services for our members. With that in mind, Ambetter 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 interventional spine pain management services (IPM), and inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Ambetter of Illinois 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.

In consideration of this agreement, effective January 31, 2024, Ambetter will terminate the current MSK program with TurningPoint Healthcare.

Under terms of the agreement between Ambetter and NIA:

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

Planned for a February 1, 2024, implementation, this correspondence serves as notice under your Participating Ambetter of Illinois Provider Agreement of changes to the program. Providers may begin contacting NIA on February 1, 2024, to seek prior authorization for procedures scheduled on or after February 1, 2024.

The following outlines the specific procedures requiring prior authorization.

IPM Component: Prior authorization will be required for the following non-emergent outpatient IPM services:

• Spinal Epidural Injections
• Paravertebral Facet Joint Injections or Blocks
• Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)
• Sacroiliac Joint Injections
• Implantable Infusion Pump Insertion 
• Sympathetic Nerve Blocks
• Spinal Cord Stimulators

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 knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, 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 & Multiple Levels
  • 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 IPM procedures and MSK surgeries managed by NIA.
• NIA does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those procedures listed above.
• The ordering physician must obtain prior authorization with NIA prior to performing the surgery/procedure.
• Facility admissions do not require a separate prior authorization. However, the facility should ensure that an NIA prior authorization has been obtained prior to scheduling the surgery/procedure.

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

We appreciate your support and look forward to your assistance in assuring that Ambetter members 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 have questions, please contact Ambetter Provider Services at 855-745-5507, TTY: 844-517-3431.