NIA Magellan 1 Medical Specialty Solutions 1 NIA Magellan refers to National Imaging Associates, Inc.
NIA Magellan Training Program 2
NIA Magellan Program Agenda Introduction to NIA Magellan Our Program 1. Authorization Process 2. Other Program Components 3. Provider Tools and Contact Information RadMD Demo Questions and Answers 3
Magellan Today and Building for the Future Medical • Advanced Diagnostic imaging • Cardiac imaging and interventional Specialty procedures Solutions • Radiation Oncology NIA Magellan • Pain Management Multiple Solutions One Magellan • • Behavioral health As the nation’s leading Behavioral Health • • Substance use specialty health care • • Integrated medical & behavioral care Solutions management company, • • EAP and health and wellness we deliver Magellan BH • • Psychotropic drug management comprehensive and innovative solutions to improve quality • Total drug management Pharmacy outcomes, optimize cost • Medical pharmacy Solutions of care. • Specialty pharmacy TDS • Pharmacy benefits 4
NIA Magellan Highlights Industry Clinical NIA Facts Product Portfolio Presence Leadership • Providing Client • Strong panel of • Advanced Diagnostic • 55 Health Plan Solutions since 1995 internal Clinical Imaging Clients serving leaders – client 19.5M National Lives • Magellan Acquisition • Cardiac Solutions consultation; clinical (2006) • 10M Commercial; • Radiation Oncology framework 1M Medicare; 6M •Columbia, MD with • OB Ultrasound • Supplemented by Medicaid 500 National NIA • Musculoskeletal broad panel of Magellan Employees • 29 states Management (Spine external clinical •Business supported by • Doing business in Surgery/IPM) experts as two National Call Pennsylvania since • Sleep Management consultants (for Operational Centers 2005, serving 2.9 guidelines) • Emergency million lives Department, Provider Profiling & Practice Management Analysis URAC Accreditation and NCQA Certified 5
NIA Magellan’s Prior Authorization Program Effective December 1, 2009 – HealthAmerica Only non-emergent procedures performed in an outpatient setting require authorization from NIA Magellan • CT/CTA • MRI/MRA • PET • Diagnostic Nuclear Medicine Procedures Requiring • CCTA Prior Authorization • Stress Echo • Nuclear Cardiology/Nuclear Stress/MPI • Cardiac Catheterization • Hospital Inpatient • Observation Excluded from Program: • Emergency Room Procedures Performed in • Urgent Care the Following Settings: • Surgery Center 6
List of CPT Procedure Codes Requiring Prior Authorization • Review Claims/Utilization Review Matrix to determine CPT codes managed by NIA Magellan • CPT Codes and their Allowable Billable Groupings • Located on RadMD INSERT HEALTH PLAN SPECIFIC • Defer to Health Plan Policies for Procedures MATRIX SCREEN SHOT not on Claims/Utilization Review Matrix 7
Responsibility for Authorization Ordering Provider Rendering Provider Responsible for obtaining prior Ensuring that prior authorization has authorization been obtained prior to providing service Recommendation to Rendering Providers: Do not schedule test until authorization is received 8
Prior Authorization Process Overview Algorithm Online Through Telephone NIA Ordering Rad MD Magellan’s Call Physician www.RadMD.com Center Rendering Provider Performs Service Service Authorized Claim 9 9
Clinical Decision Making and Algorithms • Guidelines are reviewed and mutually approved by HealthAmerica and NIA Magellan Chief Medical Officers • NIA Magellan algorithms and medical necessity reviews collect key clinical information to ensure that HealthAmerica members are receiving appropriate care prior to more invasive procedures being performed. Our goal – ensure that HealthAmericas members are receiving the appropriate level of care. • Clinical Guidelines available on www.RadMD.com 10
Patient and Clinical Information Required for Authorization GENERAL CLINICAL INFORMATION Includes things like ordering physician • Includes clinical information that will information, Member information, justify examination, symptoms and their rendering provider information, requested duration, physical exam findings examination, etc. • Preliminary procedures already completed (e.g., x- rays, CTs, lab work, ultrasound reports, scoped procedures, referrals to specialist, specialist evaluation) • Reason the study is being requested (e.g., further evaluation, rule out a disorder) Refer to the Prior Authorization Checklists on RadMD for more specific information. 11
Clinical Specialty Team Review Clinical Specialization Pods Overseen by a Physician Advisor Abdomen/Pelvis Neurology General Studies Radiation Oncology Automated Timeliness Routing (includes OB-US) Cardiac Orthopedic Oncology Physician Review Team Physician Panel of Board-Certified Physician Specialists with ability to meet any State licensure requirements Specialty Physician panels for peer reviews on specialty products (cardiac, OB ultrasound, radiation oncology, pain management, sleep management) 12
Document Review • NIA Magellan may request patient’s medical records/additional clinical information • When requested, validation of clinical criteria within the patient’s medical records is required before an approval can be made • Ensures that clinical criteria that supports the requested test are clearly documented in medical records • Helps ensure that patients receive the most appropriate, effective care 13
NIA Magellan to Ordering Provider: Request for Additional Clinical Information • A fax is sent to the provider detailing what clinical information that is needed, along with a Fax Coversheet • We stress the need to provide the clinical information as quickly as possible so we can make a determination • Determination timeframe begins after receipt of clinical information • Failure to receive requested clinical information may result in non certification 14
Submitting Additional Clinical Information/Medical Records to NIA Magellan • Two ways to submit clinical information to NIA Magellan • Via Fax • Via RadMD Upload • Use the Fax Coversheet (when faxing clinical information to NIA Magellan) • Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call Center @ 866- 972 - 9642 Be sure to use the NIA Fax Coversheet for all transmissions of clinical information! 15
Prior Authorization Process 1 2 3 Intake level Initial Clinical Review Physician Clinical Review • Physicians may: 1.Approve 2.Ordering Physician • Requests are evaluated Withdrawal using our clinical algorithm 3.Deny — Peer to Peer • Requests may: Outreach 1.Approve 2.Require additional clinical • Nurses will review review request and may: 3.Pend for clinical validation 1.Approve of medical record 2. Send to physician for additional clinical review 16
Notification of Determination • Denial Notification • Approval Notification Verbal, Fax, and Written Verbal, Fax, and Written • Authorization Validity Period • Appeal Instructions In the event of a denial, The authorization number is valid for • 90 days from the date of request. providers are asked to follow the appeal instructions Cardiac Catheterization: The provided in their denial letter. authorization number is valid for two weeks prior to the date of service and two weeks following the date of service. 17
NIA Magellan’s Urgent Authorization Process Urgent Authorization Process If an urgent clinical situation exists outside of a hospital emergency room, please contact NIA Magellan immediately with the appropriate clinical information for an expedited review. 18
Program Components Provider Provider Facility Site Claims and Radiation Assessment Network Selection Appeals Safety Program
Using NIA Network Provider Provider Facility Site Claims and Radiation Assessment Selection Appeals Safety Program Network Advanced Imaging Provider Network: HealthAmerica will use both NIA Magellan's and HealthAmerica ’ network of • Free- Standing Imaging Facilities (FSFs) as it’s preferred providers for delivering outpatient CT/CTA, MRI/MRA, PET Scan, Diagnostic Nuclear Medicine, CCTA, Stress Echo, Nuclear Cardiology/Nuclear Stress/MPI, and Cardiac Catheterization I services to HealthAmerica members throughout Pennsylvania. The NIA Magellan contracted facilities will be “in network” for HealthAmerica • members. HealthAmerica Participating Hospitals and In - Office Providers: HealthAmerica Participating Hospitals, hospital - owned FSFs and Privileged In - • Office Providers offering advanced imaging services will continue under their current HealthAmerica contracts as “in - network” providers. They will need to participate in the NIA Magellan prior authorization program. 20
Recommend
More recommend
