NIA Medical Specialty Solutions Absolute Total Care Provider Training 1 - National Imaging Associates, Inc. (NIA) is a subsidiary of Magellan Healthcare, Inc.
NIA Training Program 2
NIA Program Agenda Introduction to NIA 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 Behavioral • • Behavioral Health Health • • Substance Abuse Solutions • • Integrated Medical & Behavioral Care • • EAP and Health and Wellness Magellan BH • • Psychotropic Drug Management Multiple Solutions One Magellan Pharmacy • • Total Drug Management As the nation’s leading Solutions • • Medical Pharmacy • • Specialty Pharmacy specialty healthcare Magellan Rx • • Pharmacy Benefits management company, we deliver comprehensive and • Advanced Diagnostic Imaging innovative solutions to • Cardiac Solutions • Radiation Oncology improve quality Medical • OB Ultrasound Specialty outcomes and • Genetic Testing Solutions • Musculoskeletal Management (Spine Surgery/IPM) optimize cost of care. (Chiropractic Care, Speech, Physical and Occupational Therapies) NIA • Sleep Management • Emergency Department • Provider Profiling & Practice Management Analysis 4
NIA Highlights Industry Clinical NIA Facts Product Portfolio Presence Leadership • Providing Client • Strong panel of • Advanced Diagnostic • 80 Health Plan Solutions since 1995 Clients serving internal Clinical Imaging 26.5M National Lives leaders – client • Magellan Acquisition • Cardiac Solutions consultation; clinical (2006) • 16.2M Commercial; • Radiation Oncology framework 1.2M Medicare; • Columbia, MD with • OB Ultrasound 9.1M Medicaid • Supplemented by 500 National NIA • Musculoskeletal broad panel of Employees • 28 states Management (Spine external clinical • Business supported by • Doing business in Surgery/IPM) experts as two National Call South Carolina since • Sleep Management consultants (for Operational Centers 2000 guidelines) • Emergency Department, Provider Profiling & Practice Management Analysis URAC Accreditation & NCQA Certified 5
NIA Prior Authorization Program Effective 5/01/2011 Only non-emergent procedures performed in an outpatient setting require authorization with NIA Procedures Requiring • MRI/MRA Prior Authorization • CT/CTA • PET • CCTA • Hospital Inpatient Excluded from Program: • Observation Procedures Performed in • Emergency Room 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 • CPT Codes and their Allowable Billable Groupings • Located on RadMD • Defer to Health Plan Policies for Procedures 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 Ordering RadMD Telephone NIA Call Physician Center www.RadMD.com Rendering Provider Claim Performs Service Service Authorized 9
Clinical Decision Making and Algorithms • Guidelines are reviewed and mutually approved by Absolute Total Care and NIA Chief Medical Officers • NIA algorithms and medical necessity reviews collect key clinical information to ensure that Absolute Total Care members are receiving appropriate care prior to more invasive procedures being performed. Our goal – ensure that Absolute Total Care 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 clinical information that will Includes things like ordering physician 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 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 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 • Two ways to submit clinical information to NIA ‒ Via Fax ‒ Via RadMD Upload • Use the Fax Coversheet (when faxing clinical information to NIA) • Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call Center @ 1- 888-642-7649. 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 • Member and ordering provider. • Member and ordering provider. • Authorization Validity Period • Appeal Instructions • In the event of a denial, • 30 days from the call in date. providers are asked to follow the appeal instructions provided in their denial letter. 17
NIA’s Urgent Authorization Process Urgent Authorization Process If an urgent clinical situation exists outside of a hospital emergency room, please contact NIA immediately with the appropriate clinical information for an expedited review at 1-866-433-6041. 18
Program Components Claims Provider Radiation and Network Safety Appeals
Using the NIA Network Provider Claims and Radiation Network Appeals Safety Advanced Imaging Provider Network: • Absolute Total Care will use the NIA network of Free-Standing Imaging Facilities (FSFs) as it’s preferred providers for delivering outpatient CT/CTA/CCTA, MRI/MRA, and PET Scan services to Absolute Total Care members throughout South Carolina. • The NIA contracted facilities will be “in - network” for Absolute Total Care members. Absolute Total Care Participating Hospitals and In-Office Providers: • Absolute Total Care Participating Hospitals, hospital-owned FSFs and In-Office Providers offering advanced imaging services will continue under their current Absolute Total Care contracts as “in - network” providers. 20
Claims Radiati Provider Claims and on Network Appeals Safety Claims Appeals Process How Claims Should be Submitted • Rendering providers/Imaging • In the event of a prior authorization or providers should continue to send claims payment denial, providers may their claims directly to Absolute Total appeal the decision through Absolute Care Total Care • Providers are strongly encouraged to • Providers should follow the instructions use EDI claims submission on their non-authorization letter or Explanation of Payment (EOP) • Check on claims status by logging on notification to the Absolute Total Care website at www.absolutetotalcare.com NOTE: Consistent with CMS guidelines, multiple procedure discounts are applied when appropriate. 21
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