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Preapproval Requirements

Updated January 2020

• Provider Reference Sheet
• Who to notify
• Forms
• Important notices

Preapproval reviews are conducted by UniCare’s Managed Care department or by AIM Specialty Health^SM, a UniCare-affiliated company that provides support for the preapproval process. Our Provider Reference Sheet identifies which services are reviewed by UniCare and which are reviewed by AIM and how much notice is required (see below).

You can also download our precertification worksheets and the standardized prior authorization form.

Provider Reference Sheet

Use this resource as a convenient reference for member copays, notification requirements for preapprovals, and selected procedures for pre-review. View the preapproval requirements effective September 15, 2019.

You can also visit our member page to view notification requirements for preapprovals documents provided to members. Please refer to the applicable member handbook for more information on plan benefits, conditions, limitations and exclusions.

Who to notify

About AIM’s web-based application – UniCare’s partnership with AIM lets our providers use AIM’s web-based application for services reviewed by AIM. Providers can log into the AIM application and complete the intake process for certain procedures, as noted in our Provider Reference Sheet (see above). In many cases, the entire review and approval process can be done online. Providers who already use AIM’s web application will not have to re-register for UniCare.

Express Scripts, the administrator for the prescription drug plan for UniCare's non-Medicare members, covers and dispenses self- or office-administered specialty drugs (non-oncology). In addition, some specialty drugs require review and dispensing by Express Scripts, for non-Medicare members only. The list of these specialty drugs is updated periodically and posted on this site. View the current list effective January 1, 2020.

Expanded review required for certain infused specialty drugs
If a non-Medicare member will be getting infusions of certain non-oncology specialty drugs in a hospital outpatient setting, an expanded review will be conducted to review both the drug for clinical appropriateness and the level of care/site of service. See the Provider Reference Sheet above for a link to the lists of specialty drugs that will require level of care review.

Forms

• Precertification worksheets
• Standardized prior authorization form – This form was developed by the Massachusetts Health Care Administrative Simplification Collaborative in May 2012. You can use it to submit a prior authorization request. You will also need to send the appropriate UniCare pre-certification worksheet to provide the necessary clinical documentation to support the request. Learn more about this form and when to use it.

Important Notices

UniCare now reviewing certain specialty drugs previously reviewed by AIM – Effective September 15, 2019, UniCare began reviewing all oncology specialty drugs and certain non-oncology specialty drugs that were previously reviewed by AIM. Certain other non-oncology drugs will continue to be reviewed by Express Scripts.

Updates to AIM guidelines for cardiac imaging effective January 28, 2019 – Beginning with dates of service on or after January 28, 2019, AIM Specialty Health® is revising its guidelines for certain cardiac imaging procedures. You can also view the complete text of the updated guidelines at www.aimspecialtyhealth.com.

An expanded review will be required for certain infused specialty drugs – If a non-Medicare member will be getting infusions of certain non-oncology specialty drugs in a hospital outpatient setting, an expanded review will be conducted to review both the drug for clinical appropriateness and the level of care/site of service. Learn more about this change.

See the Provider Reference Sheet above for a link to the lists of specialty drugs that will require level of care review.

For self-funded plans, claims are administered by UniCare Life & Health Insurance Company. © 2000-2020 UniCare.