Ambetter of Tennessee expanded partnership with National Imaging Associates, Inc. for Musculoskeletal Management services

Fecha: 28/03/23

In keeping with our commitment of promoting continuous quality improvement for services provided to Ambetter of Tennessee members, Ambetter of Tennessee is pleased to announce our expanded partnership with National Imaging Associates, Inc. (NIA) for Musculoskeletal (MSK) Management services. This program includes prior authorization for non-emergent MSK procedures including: outpatient, interventional spine pain management services (IPM); and inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries for Commercial members. This decision 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 Tennessee and NIA, Ambetter of Tennessee will oversee the MSK program and continue to be responsible for claims adjudication and medical policies. NIA will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient MSK surgeries through the existing contractual relationships with Ambetter of Tennessee.

Planned for a June 1, 2023, implementation, this correspondence serves as notice under your Participating Ambetter of Tennessee Provider Agreement of changes to the program.

Providers may begin contacting NIA on June 1, 2023, to seek prior authorization for procedures scheduled on or after June 1, 2023.

The following outlines the specific procedures requiring prior authorization.

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

• Spinal Epidural Injections
• Paravertebral Facet Joint Injections or Blocks
• Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)
• Sacroiliac Joint Injections

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

Hip

• Revision/Conversion Hip Arthroplasty
• Total Hip Arthroplasty/Resurfacing
• Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincher & 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

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 interventional spine pain management procedures and MSK surgeries outlined above. 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.

Any Ambetter of Tennessee prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery/procedure has met NIA’s medical necessity criteria.

Services other than the interventional spine pain management and MSK surgeries outlined above will continue to follow Ambetter of Tennessee prior-authorization requirements for hospital admissions and elective surgeries.

We appreciate your support and look forward to your assistance in assuring that Ambetter of Tennessee 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 at this time, please contact Ambetter of Tennessee Provider Services Department at 1-800-424-4945.