Spine Management Program NIA Magellan & Presbyterian Health Plan - PowerPoint PPT Presentation

Spine Management Program NIA Magellan & Presbyterian Health Plan

Training Program 2

Program Agenda • Program 1. Authorization Process 2. Other Program Components 3. Provider Tools and Contact Information • RadMD Demo • Questions and Answers 3

NIA Highlights Industry Clinical Product NIA Facts Presence Portfolio Leadership • Providing Client • • • 55 Health Plan Strong panel of Advanced Solutions since 1995 Clients serving internal Clinical Diagnostic Imaging leaders – client 19.5M National • Magellan Acquisition • Cardiac Solutions Lives consultation; (2006) • Radiation clinical framework • • Columbia , MD with 10M Commercial; Oncology • 1M Medicare; 6M Supplemented by 700 National NIA • OB Ultrasound Medicaid broad panel of Employees • Musculoskeletal • external clinical • Business supported 29 states Management experts as by two National Call (Spine consultants (for Operational Centers Surgery/IPM) guidelines) • Sleep Management • Emergency Department, Provider Profiling & Practice Management Analysis URAC Certified & NCQA Accredited 4

Prior Authorization Program • Procedures Performed on or after January 1, 2015 Require Prior Authorization NIA’s Call Center & RadMD will open December 29, 2014 • Procedures Requiring Prior Authorization Excluded from Program: Inpatient or Outpatient Lumbar & Cervical Spine Surgery  Lumbar Microdiscectomy  Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)  Lumbar Spine Fusion (Arthrodesis) With or Without Emergency Surgery – Decompression – Single & Multiple Levels admitted via the  Cervical Anterior Decompression with Fusion – Single & Emergency Room Multiple Levels  Cervical Posterior Decompression with Fusion – Single & Multiple Levels  Cervical Posterior Decompression (without fusion)  Cervical Artificial Disc Replacement  Cervical Anterior Decompression (without fusion) Please note that CPT Codes 22800-22819 used for reconstructive spinal deformity surgery and the associated instrumentation do not require NIA/Presbyterian Health Plan’s prior authorization. NIA will monitor the use of these CPT codes in claims, but prior authorization is not currently required. As long as the deformity surgery coded does not include any CPT codes on NIA’s utilization review matrix, the case will process in claims accordingly. 5

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 Presbyterian Health Plan Policies for Procedures not on Claims/Utilization Review Matrix 6

Responsibility for Authorization Surgeon Place of Service / Facility • Responsible for obtaining prior • Ensuring that prior authorization authorization has been obtained prior to providing service 7

Prior Authorization Process - Overview 8

Patient and Clinical Information Required Information for Authorization Clinical Information General • Clinical Diagnosis • Includes things like ordering physician Physical exam findings and patient information, member information, place of symptoms (including findings applicable to service, anticipated date of service, clinical the requested procedure) information, requested procedure, etc. • Date of onset of pain or exacerbation. Duration of patient’s symptoms. Special Information • Non-operative conservative treatment modalities completed, duration, and results • Only one authorization request per spine (e.g., interventional pain management surgery. Surgeon selects from the list of procedures, physical therapy , chiropractic surgical options — selecting the most or osteopathic manipulation, hot pads, complex of the procedures being massage, ice packs and/or medication) performed. • Diagnostic imaging results confirming • A fusion authorization includes symptoms and physical exam findings. decompression procedures along with instrumentation and bone grafting. • Patient’s Weight/BMI, Tobacco Status and Depression/Mental Health Status 9

Clinical Foundation & Review - NIA Clinical guidelines and algorithms were developed by Clinical Guidelines Are the practicing specialty physicians, literature reviews, and evidence base. Guidelines are reviewed and mutually approved by Foundation Presbyterian Health Plan and NIA Chief Medical Officers and Clinical Spine Experts. When requested, validation of clinical criteria within the patient’s Clinical Algorithms collect medical record is required before an approval can be made. pertinent information NIA reviews key clinical information to ensure that Presbyterian Health Plan members are receiving appropriate care prior to more invasive procedures being performed. Fax/Upload Clinical Information (upon request) NIA has a specialized clinical team focused on spine care. Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines. Clinical Review by NIA’s No change in current appeals process. Specialty Spine Clinicians Our goal – ensure that Presbyterian Health Plan members are receiving appropriate spine care. Clinical Guidelines available on www.Ra dMD.com Peer-to-Peer Discussion 10

NIA to Physician: Request for 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 11

Submitting Clinical Information/Medical Records to NIA • Two ways to submit clinical information to NIA • Via Fax • Via RadMD Upload • Coversheets are sent with all requests for clinical information • Coversheets can also be printed from RadMD or requested via the Call Center Be sure to use the NIA Coversheet for all transmissions of clinical information including uploads through RadMD! 12

Specialized Clinical Team: Focused on Spine Specialized Clinical Team Spine Surgery Reviews Surgery concierge team will Nurses will assemble surgery Only Orthopedic Spine proactively outreach for cases and reach out for clinical Surgeons or Neurosurgeons additional information, information as needed prior to conduct clinical reviews and reconsiderations and to sending to Surgeon Reviewers peer-to-peer discussion on schedule peer-to-peer session. . surgery requests. 13

Notification of Determination Authorization Notification Denial Notification Authorizations Denials • Validity Period In the event of a denial,  providers are asked to Authorizations for Spine Surgery are valid for: follow the appeal • Inpatient: 3 days from instructions provided in DOS their denial letter. • Outpatient: 60 day DOS 14

NIA’s Urgent/Expedited Authorization Process • Urgent/Expedited Authorization Process – If an urgent clinical situation exists (outside of a hospital emergency room), please call NIA immediately. – The number to obtain a prior authorization is: 1-866-236-8717 15

Summary Points: Spine Surgery • Inpatient and outpatient non-emergent spine surgeries • Region Specific: Lumbar & Cervical Spine Surgery • Only one authorization per surgery (most complex performed). • For example, prior authorization for fusion includes decompression procedures. • Date of service is required. NIA must be notified of any changes to the date of service. • NIA Spine Surgeons review surgery requests Please note that CPT Codes 22800-22819 used for reconstructive spinal deformity surgery and the associated instrumentation do not require NIA/Presbyterian Health Plan’s prior authorization. NIA will monitor the use of these CPT codes in claims, but prior authorization is not currently required. As long as the deformity surgery coded does not include any CPT codes on NIA’s utilization review matrix, the case will process in claims accordingly. 16

Spine Surgery Selection - via RadMD • Only one authorization per surgery There will be a cheat sheet of definitions and codes • Select the most complex available on RadMD procedure being performed • Fusion procedures include decompression, instrumentation and bone grafting • Summary of Surgery CPT codes available online 17

Provider Tools • Provider Tools that Make it Easy for Providers to Partner with NIA  Toll free authorization and information number 1-866-236- 8717  Available 8am – 8pm EST • Interactive Voice Response (IVR) System  RadMD Website – Available 24/7 (except during maintenance) • Different functionality for ordering and rendering providers • Request authorization and view authorization status • Upload additional clinical information • View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents 18

NIA Website - www.RadMD.com RadMD Functionality varies by user: Place of Service / Facility – Views approved authorizations for their facility Surgeon – View and submit requests for authorization Online Tools Accessed through www.RadMD.com: NIA’s Clinical Guidelines Frequently Asked Questions Quick Reference Guides RadMD Quick Start Guide Claims/Utilization Matrices 19