Specialty Solutions Coventry Health Care of the Carolinas, Inc. - PowerPoint PPT Presentation

NIA Magellan 1 Medical Specialty Solutions Coventry Health Care of the Carolinas, 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. Pre-certification 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 use • Integrated medical & behavioral care Solutions Multiple Solutions • EAP and health and wellness Magellan BH • Psychotropic drug management One Magellan As the nation’s leading • • Total Drug Management specialty health care • • Medical Pharmacy Magellan Rx management company, • • Specialty Pharmacy Specialty • • Pharmacy Benefits we deliver comprehensive and innovative solutions to improve quality • Advanced Diagnostic imaging outcomes, optimize cost Medical • Cardiac Solutions • Radiation Oncology of care. Specialty • OB Ultrasound Solutions • Musculoskeletal Management (Spine Surgery/IPM) • Sleep Management NIA Magellan • Emergency Department, Provider Profiling & Practice • Management Analysis 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 21M 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 South Carolina since guidelines) • Emergency 2000, serving almost Department, 1.8M lives Provider Profiling & Practice Management Analysis URAC Accreditation & NCQA Certified 5

NIA Magellan’s Pre -certification Program Effective August 1, 2010 Only non-emergent procedures performed in an outpatient setting require pre- certification with NIA Magellan This program excludes Coventry Health Care of the Carolinas, Inc. self-funded membership (such as GEHA) . Providers should continue to call Coventry Health Care of the Carolinas, Inc. at 1-800-708-9355 to pre-certify services below for self- funded members. • CT/CTA Procedures Requiring • MRI/MRA Pre-certification • PET Scan • CCTA • Nuclear Cardiology/Nuclear Stress/MPI • Hospital Inpatient Excluded from Program: • Observation Procedures Performed in • Emergency Room the Following Settings: • Surgery Center 6

List of CPT Procedure Codes Requiring Pre-certification • Review Claims/Utilization Review Matrix to determine CPT codes managed by NIA Magellan • 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 Pre-certification Ordering Provider Rendering Provider Responsible for obtaining pre- Ensuring that pre-certification has been certification obtained prior to providing service Recommendation to Rendering Providers: Do not schedule test until pre-certification is received 8

Pre-certification Process Overview Algorithm Telephone NIA Online Through Ordering Magellan’s Call RadMD Physician Center www.RadMD.com Rendering Provider Claim Performs Service Service Pre-certified 9

Clinical Decision Making and Algorithms • Guidelines are reviewed and mutually approved by Coventry Health Care of the Carolinas, Inc. and NIA Magellan Chief Medical Officers • NIA Magellan algorithms and medical necessity reviews collect key clinical information to ensure that Coventry Health Care of the Carolinas, Inc. members are receiving appropriate care prior to more invasive procedures being performed. Our goal – ensure that Coventry Health Care of the Carolinas, Inc. members receive the appropriate level of care. • Clinical Guidelines available on www.RadMD.com 10

Patient and Clinical Information Required for Pre-certification 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 Pre-certification 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 @ 1-888-642-7649 Be sure to use the NIA Magellan Fax Coversheet for all transmissions of clinical information! 15

Pre-certification 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! 16

Notification of Determination • Pre-certification Validity Period • Appeal Instructions • In the event of a denial, 30 days from date of final determination. providers are asked to follow the appeal instructions provided in their denial letter. 17

NIA Magellan’s Urgent Pre -certification Process Urgent Pre-certification 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 1-800-642-2809. 18

Program Components Facility Claims Provider Radiation Site and Network Safety Selection Appeals

Facility Claims Using Coventry Health Provider Radiation Site and Safety Selection Appeals Network Care of the Carolinas, Inc. Network Advanced Imaging Provider Network: • Coventry Health Care of the Carolinas, Inc. will use the Health Plan’s network of Free- Standing Imaging Facilities (FSFs), Hospitals, and In Office Providers as it’s preferred providers for delivering outpatient CT/CTA, MRI/MRA, PET Scan, CCTA, and Nuclear Cardiology/Nuclear Stress/MPI services to Coventry Health Care of the Carolinas, Inc. members. 20

Overview of Facility Site Facility Site Provider Claims and Radiation Network Selection Appeals Safety Selection An integrated approach to helping providers and consumers select high quality, convenient, and cost effective facilities for advanced imaging services. NOTE: Primary consideration is always the clinical aspect of the member when making facility recommendations GOALS: • Educate the member and the ordering provider on imaging facility choices and potential cost implications • Enhance the patient experience by helping them select a facility that is convenient and by offering to help schedule in-network services • Some requests for service are exempt from Facility Site Selection based on the clinical needs of the member 21