Transcript Slide 1

Provider Training
Program
2010
Presenter:
Date:
Provider Training Program Agenda
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Welcome and Opening Remarks
About National Imaging Associates, Inc.
Provider Partnership
Program Components
The Privileging Process
Facility Selection Support Program
How the Program Works:
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Authorization Process
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Algorithms Guidelines
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Radiation Awareness
• Authorization Appeals Process
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Claims Process
• Claims Appeals Process
Provider Self-Service Tools (RadMD and IVR)
RadMD Demonstration
NIA Provider Relations and Contact Information
Questions and Answers
NIA—A Magellan Health Company
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About National Imaging
Associates
NIA is accredited by
NCQA and URAC
National Imaging Associates (NIA) - chosen by national and regional health
plans, serving more than 19 million members, and offering:
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Distinctive clinical focus
National Committee for Quality Assurance accreditation and Utilization
Review Accreditation Commission certification
Stability reinforced by parent company, Magellan Health Services
Enhanced operational competencies
Strong IT capabilities
Comprehensive patient support tools
Financial stability promoting growth and investment in innovative
technology
Focus and Results - Maximizing quality diagnostic services and promoting
patient safety through:
• A clinically-driven process that safeguards appropriate diagnostic
treatment for Geisinger Health Plan1 members.
• Convenient access to a network of qualified providers
1 Geisinger Health Plan, Geisinger Indemnity Insurance Company, and Geisinger Quality Options, Inc. shall be collectively referred to
herein as "the Health Plan
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The NIA Provider Partnership Model
• Dedication to Provider Service and Convenience
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Dedicated provider relations staff
Authorization call center
Interactive Voice Response (IVR) tool
Innovative provider support tool – RadMD
• Education and training programs
• Ongoing outreach to providers
• Provider newsletters
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Program Components
• Utilization Management/Authorizations: NIA's proprietary, evidence-based
decision algorithms support scripting for call center representatives or online, leading
to quick procedure approval or consultation with our radiology experts.
• Information and Transaction Tools: Our online resource, www.RadMD.com,
gives ordering providers the ability to request and obtain authorizations, reference
lists of nearby imaging facilities, locate authorizations and submit rapid authorization
requests. Providers report a high level of satisfaction with their use of RadMD, finding
it a simple tool to use and a time-saver for staff.
• Provider Privileging: The program includes privileging of the Health Plan’s
freestanding facilities and the Health Plan’s in-office providers for advanced and
cardiac imaging. The program promotes continuous quality improvement, provides
scope of practice limitations and enables consumers to make educated health care
decisions. Hospitals are excluded from the privileging program.
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The Privileging Process
for Rendering
Providers
NIA’s Privileging Program
• NIA has a Comprehensive Program for Evaluating Imaging Providers
Selected to Participate in the Health Plan Outpatient Imaging Program
• Primary Purpose of the NIA Privileging Program:
• To ensure the Health Plan imaging providers meet the standards
required to adequately perform the technical and professional
components outlined in the outpatient imaging program.
• Select information from provider privileging application feeds the Consumer
Portal – this data enables members to make educated health care decisions.
The Health Plan members have the added assurance that all NIA privileged
imaging providers meet the high technical and professional standards
required to deliver imaging services safely.
• Please note: Free-standing facilities and in-office providers should complete
a privileging assessment application in order to continue to provide
advanced diagnostic imaging services to Health Plan members beginning
February 1, 2011.
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Facility Selection Support
Program
Facility Selection Support Goals
The facility selection process is based on patient support and cost effectiveness.
• Primary consideration is always the clinical aspect of the patient when
making facility recommendations.
• Helps ensure that patients go to quality imaging facilities that are
conveniently located.
• Supports the education of both the provider and patient about costeffective facility alternatives.
• Facilitates the delivery of tests at free-standing, outpatient facilities (when
appropriate) to support lower costs
NIA—A Magellan Health Company
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How Facilities are Selected
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During prior authorization, the
authorization representative will help
the ordering provider select a facility
based on:
• Facilities meeting NIA’s quality
requirements and patient’s
clinical need
• Location and cost differential
• Convenience items important to
patient
• Prior Authorization for a high cost
facility will be confirmed with the
consumer if there is no clinical
justification
All facilities meeting NIA’s approved facility
requirements for the indicated test. Facilities
also meet the patient’s clinical requirements
Facilities located in or close to
required zip code. Preference
given to lower cost facilities
Facilities with
requested
convenience
items
Facility
Selected
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Convenient Services that can be
Selected
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Transportation and Parking
• Public transportation accessibility
• Free parking
• Language Assistance
• Languages spoken by office staff
• Telecommunication equipment for deaf patients
• Weekend or Evening Hours
• Extended evening hours
• Weekend hours
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The Authorization
Process
NIA Prior Authorization is required for:
Non-emergent outpatient, short stay and urgent care
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CT/CTA Scan
CCTA
MRI/MRA
PET Scan
Diagnostic Nuclear Medicine
Nuclear Cardiology/MPI
Echocardiography
Stress Echo
• Any code specifically cited in the Health Plan/NIA Billable CPT® Code
Claims Resolution Matrix.
• All other procedures will be adjudicated and paid by the Health Plan per
their guidelines.
• Authorizations are valid for sixty (60) days from date of initial request.
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NIA Prior Authorization is not required
for:
• Inpatient, Observation or Emergency Room:
• CT/CTA
• CCTA
• MRI/MRA
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PET Scan
Diagnostic Nuclear Medicine
Nuclear Cardiology/MPI
Echocardiography
Stress Echo
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NIA’s Authorization Process
• The ordering physician is responsible for obtaining prior authorization.
• The rendering provider must ensure that prior authorization has been
obtained, and it is recommended that you not schedule procedures without
prior authorization.
• Procedures performed without proper authorization will not be reimbursed
and may not be billed to the Health Plan members.
• If the radiologist or rendering provider feels that, in addition to the study
already authorized, an additional study is needed the radiologist or
rendering provider should proceed with the additional study and contact
NIA within 1 business day to initiate the medical necessity review process.
• If an urgent clinical situation exists outside of a hospital emergency room,
the radiologist or rendering provider should proceed with the study and
contact NIA the next business day to go through the normal review process.
• Separate prior authorization numbers are not needed for CT-guided biopsy
and CT-guided radiation therapy.
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The NIA Prior Authorization Process
Nurse level
Agent level
Physician’s
office contacts
NIA for prior
consultation
via web or
telephone
P
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Procedure is
approved by
agent
Case is
transferred to
nurse for
review
P
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Procedure is
approved by
nurse
Case is
transferred to
physician for
review
Typically 92% of all cases receive final determinations within 24-48 hours
* Requests related to cardiac modalities that require physician review are
reviewed by cardiologists
Physician level
P
Procedure is
approved by
a physician
reviewer
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Procedure is
denied by a
physician
reviewer
x
Case is
withdrawn by
the ordering
physician
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NIA OCR Fax Cover Sheet – Submission
of Clinical Information
• NIA utilizes OCR technology which allows us to attach the clinical
information that you send to be automatically attached to an existing
preauthorization request.
• For the automatic attachment to occur you must use the NIA Fax Cover
Sheet as the first page of your fax.
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You can obtain an NIA Fax Cover Sheet in the following ways.
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If you have submitted your preauthorization request on-line through RadMD, at
the end of your submission of the preauthorization request you are given the
option to print the cover sheet.
• On RadMD click on the link “Request a Fax Cover Sheet”. This will allow you
to print the cover sheet for a specific patient.
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By calling the NIA Clinical Support Department at 1-888-642-7649 you can
request a cover sheet be faxed to you.
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If we have sent you a fax requesting additional clinical information the NIA Fax
Cover Sheet should accompany the request.
• Following this process it will facilitate a timely and efficient case review.
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Algorithms/Guidelines
Clinical Validity of Algorithms
• NIA currently reviews more than 450,000 advanced imaging requests each
month.
• All algorithms and guidelines are reviewed and approved by the Health Plan
Medical Directors.
• Some of our current algorithms recommend the substitution of alternate but
equally effective imaging technology. Our goal is to suggest the most
clinically appropriate test early in an episode of care.
• Consultative communication is a hallmark of NIA – NIA has a team of 75
board-certified physicians representing radiology and a host of other
specialties available for physician to physician discussions. Cardiac
services are reviewed by cardiologists.
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Enhanced Algorithms
 Enhanced algorithms effective January 2010 for Lumbar Spine MRI,
Shoulder MRI and Knee MRI
 As a result, NIA began asking a few additional questions to obtain more
details on the patient and his or her condition. This allowed NIA to make the
best clinical decision
 NIA's team of clinical experts uses physician-developed criteria and
proprietary algorithms based on information from their clinical database
 If the authorization is not given during the initial intake process, the case
will be forwarded to NIA’s clinical department for review. If the
authorization request does not meet clinical criteria at the nurse review
level, it will be escalated to physician review. At that point, the NIA
physician may ask for more clinical information or request to have a peer
discussion with the ordering physician. No request is ever denied without
the opportunity to consult with one of NIA’s physicians
Guidelines on RadMD
NIA’s clinical guidelines can be easily accessed on RadMD
•Open your web
browser to
www.radmd.com
•Click on the View
Clinical Guidelines
Link
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Guidelines on RadMD cont’d
•On the next
screen, click
on Clinical
Guidelines
Search
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Guidelines on RadMD cont’d
This screen allows you to select:
•Health Plan
•Type of Study
•Exam
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Guidelines on RadMD cont’d
The requested clinical guidelines will be displayed in a pop up box in
Adobe format. These guidelines can be saved to your computer or
printed for reference.
NIA—A Magellan Health Company
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Radiation Awareness
Radiation Awareness Program
NIA, in partnership with the Health Plan, has implemented a Radiation
Awareness Program to educate the provider community on radiation
exposure.
Goals of the Program
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Inform ordering providers of past exposure
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Offer provider education and consultation
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Educate providers about the risk vs. benefits of ionizing radiation
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Radiation Awareness Program
Distinguishing Features
• Claims-based, member-specific radiation accumulator
• NIA will advise ordering providers of patients with high level exposure (=>50
mSv cumulatively while with the Health Plan) to radiation during authorization
requests and offer peer-to-peer consultation.
• Provider educational content is available
• Medical necessity decisions are not impacted by the patient’s radiation
exposure - information is intended to assist the provider with the member’s
care.
More information on radiation awareness is available on our website,
www.RadMD.com.
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The Authorization
Appeals Process
The Authorization Appeals Process
• In the event of a denial or you are not satisfied with a medical decision, you
may appeal the decision.
• You will receive a denial letter that contains appeal information.
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The Claims Process
How Claims Should be Submitted
• Rendering providers/imaging providers should continue to send their claims
directly to the Health Plan at:
PO Box 8200
Danville, PA 17821
• Providers are strongly encouraged to use EDI claims submission with the
Health Plan.
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Claims Process Overview
Claim
GHP
Pends claims
and routes to
NIA
NIA
Matches Auths
and Applies
Edits
Send Member
EOB
GHP
Applies Benefits
and Issues
Checks and
EOP/EOBs
Send Provider
Check and EOP
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The Claims Appeals
Process
The Claims Appeals Process
• In the event of a prior authorization or claims payment denial, you may
appeal the decision through the Health Plan.
• Follow the instructions on your denial letter or explanation of payment
notification.
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Self Service Tools
and Usage
Multi-Channel Provider Relations Strategy
Internet Offerings
• Initiate Authorization (Ordering Provider)
• Authorization Inquiry
• Privileging
Interactive Voice Response
Radiology
Provider
IVR – Interactive Voice Response
• Authorization Inquiry
Provider Relations Staff
• Provider Forums/Education
• Centralized and Regional Support
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Self Service Tools and Uses
• Interactive Voice Response (IVR)
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Use tracking number to check case status
• Web site: www.RadMD.com
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Use tracking number to review an exam request
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NIA Web Site www.RadMD.com
The NIA web site gives providers access to:
• Information concerning approved
authorizations. Go to www.RadMD.com
and login with username and password.
• Search the site using the patient’s ID
number, name or authorization number.
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NIA Web Site – Ordering Providers
The NIA web site supports ordering providers with:
• Instant, easy access to high tech imaging prior authorization information
• Online authorization of most cases; pended cases will be resolved through
our Clinical Review Department
• Up-to-the-hour information on member authorizations, including date
initiated, date approved, exam category, valid billing codes and much more
We encourage ordering providers to submit all requests on line.
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NIA Web Site - Imaging Facilities
The NIA web site supports imaging facilities and providers with:
• User friendly, near-real-time Internet tool
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Available Monday – Friday, 5:00 a.m. to 12:00 a.m. Eastern Time;
Saturday 8:00 a.m. to 1:00 p.m. Eastern Time
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Log on to RadMD for direct access to members’ authorization information,
including:
• Date initiated
• Exam requested
• Valid billing codes (CPT)
• Current provider news
• Access to a full range of helpful content, Diagnostic Imaging Guidelines and
Quick Reference Guide
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To get started, visit www.RadMD.com
• Login and click the new user button on the right side of the home page.
• Fill out the application and click the submit button.
• You must include your e-mail address in order for our webmaster to respond
to you with your NIA-approved username and password.
• HIPAA regulations require everyone in your organization to have his or her
own username and password.
• On subsequent visits to the site, click the login button to proceed.
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RadMD Demonstration
NIA Provider
Relations
Provider Relations Structure and Portals
• Kristy S. Over, dedicated NIA Provider Relations Manager for The Health
Plan providers will:
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Serve as a liaison for The Health Plan Provider Relations and NIA.
Contact information:
• Phone 410-953-2620
• E-mail at [email protected]
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Questions and
Answers