FAQs: Members

Frequently asked questions for health plan members

How are requests for clinical appropriateness review initiated with AIM?
Your doctor can initiate a request for clinical appropriateness review by contacting AIM at the phone number indicated on the back of your health plan medical card.

Which services require review?
The lists differ depending on the health plan. Your member materials (usually the member handbook or the health plan’s website) from the health plan should have the list of services that require approval. If you have additional questions about which services require approval under an AIM program, please contact the number on the back of your health plan card for your health plan’s member services department.

Can I see if a utilization review request has already been processed?
Your doctor is responsible for providing information about you and your health history to AIM in order to review the request. AIM talks directly with your doctor, as he/she is responsible for the care that you receive. If you have a question about whether AIM has approved the request, please contact your doctor.

How can I receive a copy of the clinical criteria used by AIM?
The clinical guidelines developed by AIM are available on our website, www.aimspecialtyhealth.com.

Who makes the decisions on the requests?
If staff cannot approve a request, a doctor reviews the information given by your doctor. Your doctor is given a chance to talk to the AIM doctor. If after talking to your doctor and reviewing the information the service cannot be approved, an AIM doctor makes the decision.

How do I know when the service is not approved?
When AIM makes a decision that your condition and history does not require the service requested, you are notified of the decision in a letter. Your doctor also receives a copy of the letter that explains why the service was not approved.

How long will it take AIM to make a decision on the request?
If the decision needs to be made quickly (expedited) because of an urgent situation, it will be made in 72 hours, after the information is received. If the decision does not need to be made quickly, the decision will be made by AIM within 15 business days and prior to the date of service. You will be notified in writing of any denial decision, and the letter will tell you why the decision was made and any appeal rights you have available.

How can I find appeal information if a request is denied?
When AIM makes a decision that your condition and history does not support the service requested, you are notified of the decision in a letter, as above. This letter gives you the information on how to appeal the decision made by the AIM doctor.