NIA Magellan 1 Medical Specialty Solutions Coventry Health Care of Georgia, Inc. Provider Training 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 • Advanced Diagnostic imaging • Cardiac Solutions Medical • Radiation Oncology Specialty • OB Ultrasound Solutions Multiple Solutions • Musculoskeletal Management (Spine Surgery/IPM) • Sleep Management NIA Magellan One Magellan • Emergency Department, Provider Profiling & Practice Management Analysis As the nation’s leading specialty health care • • Behavioral health Behavioral management company, • • Substance use Health we deliver • • Integrated medical & behavioral care Solutions • • EAP and health and wellness comprehensive and • • Psychotropic drug management Magellan BH innovative solutions to improve quality outcomes, optimize cost of care. Pharmacy • Total drug management • Medical pharmacy Solutions • Specialty pharmacy • Pharmacy benefits TDS 4
NIA Magellan Highlights NIA Magellan Industry Clinical Product Portfolio Facts Presence Leadership • Providing Client • Strong panel of • Advanced Diagnostic • 54 Health Plan Solutions since 1995 Clients serving internal Clinical Imaging nearly 21 M National leaders – client • Magellan Acquisition • Cardiac Solutions Lives consultation; clinical (2006) • Radiation Oncology framework • 12M Commercial; •Columbia, MD with • OB Ultrasound 1M Medicare; • Supplemented by 700 National NIA • Musculoskeletal broad panel of Magellan Employees • 7.5M Medicaid Management (Spine external clinical •Business supported by • 28 states Surgery/IPM) experts as two National Call • Doing business in • Sleep Management consultants (for Operational Centers Georgia since 2004, guidelines) • Emergency serving over 500,000 Department, lives Provider Profiling & Practice Management Analysis URAC Accreditation & NCQA Certified 5
NIA Magellan’s Prior Authorization Program September 1, 2012 Only non-emergent procedures performed in an outpatient setting require authorization with NIA Magellan • MRI/MRA Procedures Requiring • CT/CTA Prior Authorization • PET Scan • CCTA • Nuclear Cardiology/Nuclear Stress/MPI • Stress Echo • Hospital Inpatient Excluded from Program: • Observation Procedures Performed in • Emergency Room the Following Settings: • Surgery Center 6
NIA Magellan’s Prior Authorization Program Non-Emergent Outpatient: Coventry Health Care of Georgia, Inc. Modalities Requiring NIA Magellan Prior Plans Authorization MRI/MRA, CT/CTA, PET Scan, CCTA, Nuclear Commercial HMO, POS, PPO, Coventry One Cardiology/Nuclear Stress/MPI, Stress POS, SAVNA Echocardiography MRI/MRA, CT/CTA, PET Scan, CCTA, Nuclear Medicare Cardiology/Nuclear Stress/MPI, Stress Echocardiography • All plan types not managed in this program must continue to follow Coventry Health Care of Georgia, Inc. current prior authorization requirements. • Any code that is specifically cited in the Coventry Health Care of Georgia, Inc. / NIA Magellan Utilization Review Matrix. • All other procedures will be authorized and paid by Coventry Health Care of Georgia per their payment policy. 7
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 8
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 9
Prior Authorization Process Overview Algorithm Telephone NIA Online Through Ordering Magellan’s Call RadMD Physician Center www.RadMD.com Rendering Provider Claim Performs Service Service Authorized 10
Clinical Decision Making and Algorithms • Guidelines are reviewed and mutually approved by Coventry Health Care of Georgia, Inc. and NIA Magellan’s Chief Medical Officers • NIA Magellan’s algorithms and medical necessity reviews collect key clinical information to ensure that Coventry Health Care of Georgia, Inc. members are receiving appropriate care prior to more invasive procedures being performed. Our goal – ensure that Coventry Health Care of Georgia, Inc. members are receiving the appropriate level of care. • Clinical Guidelines available on www.RadMD.com 11
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. 12
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) 13
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 14
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 15
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 @ 1-888-642-7649. Be sure to use the NIA Magellan Fax Coversheet for all transmissions of clinical information! 16
Prior Authorization Process Intake level Initial Clinical Review Physician Clinical Review • Physicians may: 1.Approve 2.Deny • Requests are evaluated using our clinical algorithm • Requests may: 1.Approve 2.Require additional clinical • Nurses will review review request and may: 3.Pend for clinical validation 1.Approve of medical records 2.Send to NIA Magellan physician for additional clinical review* A peer to peer discussion is always available! 17
Notification of Determination • Authorization Validity Period • Appeal Instructions In the event of a denial, 60 days from date of request. • providers are asked to follow the appeal instructions provided in their denial letter. 18
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 1-800-509-1842. 19
Program Components Provider Provider Facility Site Claims and Radiation Assessment Network Selection Appeals Safety Program
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