healthplus amerigroup provider training program€¦ · provider training program agenda •...

HealthPlus Amerigroup Provider Training Program

Provider Training Program Agenda

• Welcome and Opening Remarks • About NIA • The Provider Partnership • The Program Components • How the Program Works:

– The Authorization Process o The Authorization Appeals Process

– The Claims Process o The Claims Appeals Process

• Provider Self-Service Tools (RadMD and IVR) • RadMD Demo • NIA Provider Relations and Contact Information • Questions and Answers

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National Imaging Associates (NIA)

About NIA

• National Imaging Associates (NIA) – chosen as the solution for national and regional health plans covering more than 17 million lives due to: o Distinctive clinical focus o NCQA accreditation and URAC certification o Innovation and stability from parent company, Magellan Health

Services, which: – Enhances operational competencies, IT capabilities and patient

support tools – Affords financial stability for growth and continued investment in

innovative technology

• Focus/results: Maximizing diagnostic services value and promoting patient safety through: o A clinically driven process that safeguards appropriate diagnostic

treatment for HealthPlus Amerigroup members

NIA is accredited by NCQA and is URAC-certified

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The NIA Partnership Model

• Dedication to provider service and convenience o Dedicated provider relations staff o Authorization call center o Interactive Voice Response (IVR) o Education and training programming o Ongoing outreach to providers

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Outpatient Imaging Program Components

Prior Authorization/ Utilization Management

NIA's proprietary, evidence-based decision support 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 website, RadMD.com, provides the ability for ordering providers to request and obtain authorizations, reference lists of nearby imaging facilities, locate authorizations given, and gain 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.

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The Authorization Process

• Nonemergent outpatient: o CT /CTA o MRI/MRA o PET scans o Nuclear cardiology

• Any code specifically cited in the HealthPlus Amerigroup/NIA Billable CPT Codes Claims Resolution Matrix handout

The CPT Claims Resolution Matrix is available on www.RadMD.com. All other procedures will be authorized and paid by HealthPlus Amerigroup per their payment policy.

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NIA Prior Authorization is required for:

• Emergency room, urgent care centers, inpatient and observation: o CT /CTA o MRI/MRA o PET scans o Nuclear cardiology

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NIA Prior Authorization is not required for:

NIA Clinical Expertise and Provider Engagement NIA reviews more than 450,000 advanced

imaging provider requests each month.

Algorithms and guidelines are reviewed and mutually approved by the HealthPlus Amerigroup and NIA Chief Medical Officers.

Many NIA algorithms recommend substituting more costly but more effective imaging technology. Our goal – the most appropriate test early in an episode of care for HealthPlus Amerigroup members.

Clinical consultation is a hallmark of NIA – we have 86 board-certified physicians representing radiology and a host of other specialties available for physician-to-physician (peer-to-peer) discussion.

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Physicians’ office contacts NIA for prior authorization of study

Clinical information complete – procedure

approved

Clinical information not complete –

additional information needed

System evaluates request based on physician entered information

Request for specific clinical

information needed

Additional clinical information complete

– procedure approved

Additional clinical not complete or

inconclusive

Nurse/Clinical Specialty Team Review

Physician approves

case without peer-to-peer

Physician approves case with

peer-to-peer

Physician denies case

Physician Review

Ordering physician withdraws case W

92% of all cases receive final determinations in 24 – 48 hours.

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NIA Clinical UM Authorization Process

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• The ordering physician is responsible for obtaining prior authorization.

• The rendering provider must ensure 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.

• If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed, please contact NIA immediately with the appropriate clinical information for an expedited review. The number to call to obtain a prior authorization is 1-800-642-7565.

• If an emergency clinical situation exists outside of a hospital emergency room, please contact NIA immediately with the appropriate clinical information for an expedited review. The number to call to obtain a prior authorization is 1-800-642-7565.

• Separate prior authorization numbers are not needed for CT-guided biopsy, CT-guided radiation therapy and some MR-guided procedures.

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NIA Authorization Process

NIA OCR Fax Cover Sheet – Submission of Clinical Information

• NIA does not accept faxes for initial authorization requests. • NIA utilizes OCR technology which allows us to attach the clinical

information that providers send to be automatically attached to an existing prior authorization request.

• For the automatic attachment to occur, providers must use the NIA Fax Cover Sheet as the first page of the fax.

• Providers can obtain an NIA Fax Cover Sheet in the following ways: o If submitting a prior authorization request online through RadMD, at the end of the

submission, the provider is given the option to print the cover sheet. – On RadMD, click on Request a Fax Cover Sheet. This will allow the provider to

print the cover sheet for a specific patient. o By calling the NIA Clinical Support Department at 1-888-642-7649, providers can

request that a cover sheet be faxed to them. o If we have sent a fax requesting additional clinical information, the NIA Fax Cover

Sheet should accompany the request. • Following this process will ensure a timely and efficient case review.

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Requests Pended for Clinical Review Upload clinical documentation or use Fax Cover Sheet

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The Authorization Appeals Process

The Authorization Appeals Process

• Appeals are processed by HealthPlus Amerigroup

• The ordering provider and member will receive verbal and written notification.

Medical Appeals HealthPlus, an Amerigroup Company P.O. Box 62429 Virginia Beach, VA 23466

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The Claims Process

How Claims Should Be Submitted

• Rendering providers/imaging providers should continue to send their claims electronically directly to HealthPlus Amerigroup

• HealthPlus Amerigroup payer ID numbers: o Emdeon: 27514 o Capario (formerly MedAvant): 28804 o Availity: 26375

• If unable to bill electronically, claims for HealthPlus Amerigroup members

should be submitted to: HealthPlus, an Amerigroup Company

P.O. Box 61010 Virginia Beach, VA 23466-1020

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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 HealthPlus Amerigroup.

o Follow the instructions on your nonauthorization letter or Explanation of Payment (EOP) notification.

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Self-Service Tools and Usage

Multichannel Provider Relations Strategy

Radiology Provider

Interactive Voice Response

Internet Offerings • Initiate Authorization (Ordering Provider) • Authorization Inquiry

Provider Relations Staff • Provider Forums/Education • Centralized and Regional Support

IVR – Interactive Voice Response • Authorization Inquiry

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Self-Service Tools and Usage

• Interactive Voice Response (IVR)

o Use tracking number to check status of cases

• Website: www.RadMD.com

o Use tracking number to review an exam request

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NIA Website: www.RadMD.com

• Information concerning approved authorizations can be viewed at www.RadMD.com after login with username and password

• Providers may search based on the patient’s ID number, name or authorization number

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NIA Website: Imaging Facilities

• User-friendly, near-real-time Internet tool offered by NIA o Log on to www.RadMD.com

• Website offers access to:

o Member prior authorizations

– Date initiated

– Exam requested

– Valid billing codes (CPT)

o Helpful resources, including Clinical Guidelines for Radiology Procedures

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• 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 email address in order for our Webmaster to respond

to you with your NIA-approved username and password.

• Everyone in your organization is required to have his or her own separate username and password due to HIPAA regulations.

• On subsequent visits to the site, click the Login button to proceed.

To get started, visit www.RadMD.com

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NIA Contact Information

• NIA Provider Relations Manager: Charmaine Gaymon Phone: 410-953-2615 Email: csgaymon@magellanhealth.com

• Provides educational tools to ordering and rendering providers on imaging processes and procedures.

• Liaison between HealthPlus Amerigroup Provider Relations and NIA.

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RadMD Demonstration

Questions & Answers