prior authorization of physical therapy, occupational
TRANSCRIPT
© 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.
Prior Authorization of Physical Therapy, Occupational Therapy, Speech Therapy, and Chiropractic Services
Provider Orientation
Corporate Overview
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© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Comprehensive
Solutions9The industry’s most
comprehensive clinical
evidence-based guidelines
4k+ employees including
1k clinicians
Engaging with 570k+ providers
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intelligent technology
100M Members
Managed
Nationwide
3
Headquartered in Bluffton, SC
Offices across the US including:
• Melbourne, FL
• Plainville, CT
• Sacramento, CA
• Lexington, MA
• Colorado Springs, CO
• Franklin, TN
• Greenwich, CT
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
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© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information. 4
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Musculoskeletal Solution
Experience
• 8 years’ experience - since 2008
• 30+ regional and national clients
• 34M total membership
• 25.5M Commercial membership
• 2M Medicare membership
• 6.5M Medicaid membership
• 3,120 average cases built per day
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Our Clinical Approach
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Musculoskeletal by the Numbers
44Musculoskeletal
physicians on staff
66Musculoskeletal-trained
nurses on staff
35Million lives
covered
56Musculoskeletal
therapists (PT/OT/ST/MT/CHIRO/ACU)
• American Academy of Neurology
• American College of Rheumatology
• American Association of Neurological Surgeons
• American Academy of Orthopedic Surgeons
• American Society of Interventional Pain Physicians
• North American Spine Society
• American College of Occupational and
Environmental Medicine
• American Academy of Physical Medicine and
Rehabilitation
• American Association of Hip and Knee Surgeons
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Evidence-Based Guidelines
The foundation of our musculoskeletal solution:
• American Pain Society
• Official Disability Guidelines
• Medicare Guidelines
• Spine Intervention Society
• American Academy of Orthopedic Surgeons
• The American Orthopedic Society for Sports Medicine
• Cochrane Reviews
• American Physical Therapy Association
• American Chiropractic Association
• American Occupational Therapy Association
• American Speech Language Hearing Association
• American Society of Anesthesiologists
Aligned with National Societies
Dedicated
pediatric
guidelines
Medicare
LCDs & NCDs
Academic
institutional
experts and
community
physician panels
Current
clinical
literature
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Service Model
The Client Provider Operations team is responsible for high-level service delivery to
our health plan clients as well as ordering and rendering providers nationwide
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Client Provider Operations
Best Colors
Client Provider
Representatives
are cross-trained to
investigate escalated
provider and health
plan issues.
Client Provider
Representatives
Client Service Managers
lead resolution of
complex service issues
and coordinate with
partners for continuous
improvement.
Client Service
Managers
Regional Provider Engagement
Managers are on-the-ground
resources who serve as the voice of
eviCore to the provider community.
Regional Provider
Engagement Managers
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Why Our Service Delivery Model Works
One centralized intake point
allows for timely identification,
tracking, trending, and reporting
of all issues. It also enables
eviCore to quickly identify and
respond to systemic issues
impacting multiple providers.
Complex issues are escalated
to resources who are the
subject matter experts and can
quickly coordinate with matrix
partners to address issues at a
root-cause level.
Routine issues are handled by
a team of representatives who
are cross trained to respond to a
variety of issues. There is no
reliance on a single individual to
respond to your needs.
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MSK Therapies
Authorization Program
for Prominence Health Plan
eviCore began accepting requests on October 24, 2016 for dates of service
November 1, 2016 and will now expand this to include southern Nevada’s
HMO/POS/POS membership effective April 1, 2018.
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Program Overview
eviCore Prior authorization
applies to services that are:
• Outpatient
eviCore Prior authorization
does not apply to services
that are performed in:
• Emergency room
• Inpatient
• Home Health
It is the responsibility of the performing provider to request prior
authorization approval for services.
Applicable Membership
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Authorization is required for Prominence Health Plan members enrolled in the
following lines of business:
• Commercial HMO
• Commercial PPO
• Commercial POS
Members who do not require prior authorization:
• Medicare
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Prior Authorization Required:
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Chiropractic Services
To find a list of CPT
(Current Procedural Terminology)
codes that require prior authorization
through eviCore, please visit:
https://www.evicore.com/implementation/pag
es/ImplementationResourceDetails.aspx?Im
pID=76
How to request prior authorization:
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Prior Authorization Requests
Or by phone:
844-224-0495
7:00 a.m. to 7:00 p.m.
(Local Time)
Monday - Friday
WEB
www.evicore.com
Available 24/7 and the quickest
way to create prior authorizations
and check existing case status
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Needed Information
MemberMember ID
Member name
Date of birth (DOB)
Performing ProviderTherapist name
National provider identifier (NPI)
Tax identification number (TIN)
Fax number
Street Address
iRequestsSelect MSMPT, MSMOT,
MSMST, and Chiropractic
services
The appropriate
diagnosis code for the
working of differential
diagnosis
If clinical information is needed, please be able to supply:
• Patient’s subjective complaints, objective examination findings, and level of function
• Information from Treatment Request Clinical Worksheet
• Information should be current (collected within the past 10 days)
• Office notes will be requested as needed
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Clinical Review Process
Easy for
providers
and staff
START
Methods of Intake
Therapist
Review
Predictive
Intelligence/Clinical
Decision Support
Appropriate
Decision
Clinician
Review
Peer-to-
peer
Real-Time Decision with Web
If you are requesting authorization before treatment begins:
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• Complete your initial evaluation
• The initial evaluation does not require prior authorization.
• Notify eviCore healthcare within 7 days of the initial visit.
• Start date should be the first day of treatment (Date of initial evaluation or visit
following if treatment was not provided during the initial visit)
• Notification requires submission of the following information:
• Patient demographics
• Provider demographics
• Minimal clinical information
• Type of condition
• Post surgical?
• If yes, date of surgery?
• If prior care, questions will be asked to determine if this is a new condition
Prior Authorization Program Process
WHAT HAPPENS NEXT?
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Your submission will receive waiver visits or be sent for clinical review
Waiver Visits
• May be available for new conditions and existing conditions where there has
been more than a 60 day gap in care
• Range from 4-10 visits for use over 30 days
• Varies depending on condition and acuity
• Repeated submissions for the same condition throughout the year will result
in a case being sent directly for clinical review
• After the waiver visits are used, you can send eviCore healthcare a request
for continuing care. Current clinical information will be required.
Clinical Review
• Current clinical information will be requested
• Collected within the seven days prior
• Clinical worksheets available at www.evicore.com under Resources /
Providers / Online Forms & Resources
Prior Authorization Program Process
How to Request Additional Visits:
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• Additional visits may be requested as early as 7 days prior to the requested
start date.
• You will be asked to submit current clinical information
• Clinical information should be current (within the past 7 days)
• Use clinical worksheets as a guide
• If condition is complex or the worksheet does not capture aspects of the
condition you want to convey, this information can be given as “additional
information”.
• The start date will be the first date you need additional visits to begin.
Prior Authorization Program Process
Overlapping Requests
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• Request for more visits within the existing approved time period
• Information you provide should explain why the visits could not be spread over
the approved period
• Review will be made to determine if additional visits are medically necessary
• Approve
• Deny additional visits within the existing approved period
• Partially approve – Visits will be approved with a new start date
• Existing authorization end date plus one day
• eviCore healthcare will approve one date extension per Approved Time Period
up to 30 days as long as the authorization has not expired.
• Date extension can be requested via the online portal.
Prior Authorization Program Process – Important Concepts
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Authorization decisions include:
• Visits
• Units – These represent the total # of CPT codes that can be billed over the
approved period
• Approved Time Period
Example – 1 visit, 4 units from 3/1/16 to 4/1/16
• Units example – 97110 x4 or 97110 x2, 97035 x1, 97112 x1
Spread the Visits/Units over the approved period to prevent a gap in care.
Prior Authorization Program Process – Important Concepts
If you are asking for authorization after services have been provided:
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Any claim submitted without an authorization on file will be denied.
• An authorization may be obtained prior to services being rendered or after, however
a retro request will need to be started if an authorization is requested after the
DOS.
• Retrospective review is allowed for commercial member however not all
commercial groups allow for retrospective review.
• You will have 365 calendar days to initiate a retro request. Please note that if you
delay obtaining an authorization and submitting your claim, the members may no
longer be participating and reimbursement may be lost.
• If a claim is submitted without an authorization on file you will have 14 calendar
days to initiate the authorization process before the claim is denied.
Prior Authorization Program Process
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Clinical Information Worksheets
• The treatment request clinical worksheets are therapy specific and designed to assist with the submission of patient and provider information for medical necessity review.
• Worksheets should be used as a guide for questions the therapist will be prompted to answer when completing the online requests.
• These worksheets should be completed by the provider during the initial consultation and treatment planning, collecting the clinical information to allow for ease of submission.
• Worksheets are available through our web portal and are therapy-specific to the treatment request.
https://www.evicore.com/solution/pages/musculoskeletal.aspx
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Examples of Clinical Worksheets
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Prior Authorization Outcomes
• All requests are processed within 2 business
days after receipt of all necessary clinical
information.
• Authorizations are typically good for 30 calendar
days from the date of determination.
Approved Requests:
• Faxed to performing provider
• Mailed to the member
• Information can be printed on demand from the
eviCore healthcare Web Portal
Delivery:
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Prior Authorization Outcomes
• Communication of denial determination
• Communication of the rationale for the denial
• How to request a Peer Review
Denied Requests:
• Faxed to the performing provider, Texas providers
will also receive a verbal denial
• Mailed to the member
Delivery:
• Providers are permitted to request a peer-to-peer
conversation with an eviCore therapist, resulting in
an overturn or an upheld denial.
Peer-to-Peer Review:
• eviCore Healthcare will be delegated for first
level member and provider appeals.
• Requests for appeals must be submitted to
eviCore within 180 days of the initial
determination
• A written notice of the appeal decision will be
mailed to the member and faxed to the provider
Appeals:
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Special Circumstances
Retrospective Studies:
• Retro Requests must be submitted with 7 days following the date of service.
Requests submitted after 7 days will be administratively denied.
• Retros are reviewed for clinical urgency and medical necessity. Turn around time
on retro requests is 30 calendar days.
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Reconsideration Requests
• A reconsideration is a post-denial, pre-appeal process that allows for the medical
necessity determination for the treatment to be reconsidered prior to going to
appeal.
• Prominence Health Plan provides an opportunity for the provider to request a
reconsideration of an adverse determination within 14 calendar days of the
decision.
• The requesting provider will have the opportunity to discuss the decision with the
clinical peer reviewer making the denial determination or with a different clinical
peer if the original reviewer is not available.
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Web Portal Services
eviCore healthcare website
• Login or Register
• Point web browser to evicore.com
• Click on the “Providers” link
Creating An Account
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To create a new account, click Register.
Creating An Account
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Select a Default Portal, and complete the registration form.
Creating An Account
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Review information provided, and click “Submit Registration.”
User Registration-Continued
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Accept the Terms and Conditions, and click “Submit.”
User Registration-Continued
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You will receive a message on the screen confirming your registration is
successful. You will be sent an email to create your password.
Create a Password
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Uppercase letters
Lowercase letters
Numbers
Characters (e.g., ! ? *)
Your password must be at
least (8) characters long
and contain the following:
Account Log-In
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To log-in to your account, enter your User ID and Password. Agree to
the HIPAA Disclosure, and click “Login.”
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Account Overview
Welcome Screen
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Providers will need to be added to your account prior to case submission. Click the “Manage
Account” tab to add provider information.
Note: You can access the MedSolutions Portal at any time if you are registered. Click the
MedSolutions Portal button on the top right corner to seamlessly toggle back and forth
between the two portals without having to log-in multiple accounts.
Add Practitioners
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Click the “Add Provider” button.
Add Practitioners
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Enter the Provider’s NPI, State, and Zip Code to search for the provider record to add
to your account. You are able to add multiple Providers to your account.
Adding Practitioners
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Select the matching record based upon your search criteria
Manage Your Account
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• Once you have selected a practitioner, your registration will be completed.
You can then access the “Manage Your Account” tab to make any necessary
updates or changes.
• You can also click “Add Another Practitioner” to add another provider to your
account.
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Case Initiation
Initiating A Case
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• Choose “request a clinical certification/procedure” to begin a new case
request.
Select Program
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Select the Program for your certification.
Select Provider
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Select the Practitioner/Group for whom you want to build a case.
Select Health Plan
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Choose the appropriate Health Plan for the case request.
Select Address
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Contact Information
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Enter the Providers’s name and
appropriate information for the
point of contact individual.
Member Information
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New patients are registered or current patients are selected from the drop down list.
Member History
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Clinical Details
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Site Selection
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Verify all information entered and make any needed changes prior to moving
into the clinical collection phase of the prior authorization process.
You will not have the opportunity to make changes after that point.
Verify Service Selection
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ICD-10 Code
ICD-10 Code
Pause/Save Option
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Once you have entered the clinical collection phase of the case process, you can save
the information and return within (2) business days to complete.
Medical Review
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If additional information is required, you will have the option to either upload
documentation, enter information into the text field, or contact us via phone.
Authorization Status
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Approval
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Once the clinical pathway
questions are completed
and the answers have met
the clinical criteria, an
approval will be issued.
Print the screen and store
in the patient’s file.
Service Options
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Select Date Extension, Continuing Care, or Build a New Case.
Authorization look up
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Eligibility Look Up
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Provider Resources
Therapy Online Resources
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Clinical Guidelines, FAQ’s, Online Forms, and other important resources can be
accessed at www.evicore.com. Click “Solutions” from the menu bar, and select the
specific program needed.
Provider Relations
Department
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Pre-Certification Call Center
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7:00 AM - 7:00 PM (Local Time): (844) 224-0495
• Obtain pre-certification or check the status of an existing case
• Discuss questions regarding authorizations and case decisions
• Change facility or CPT Code(s) on an existing case
eviCore fax number: (800) 540-2406
Provider Relations
Department
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Web-Based Services
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www.evicore.com
To speak with a Web Specialist, call 800-646-0418 (Option #2)
• Request authorizations and check case status online – 24/7
• Web Portal registration and questions
• Pause/Start feature to complete initiated cases
• Upload electronic PDF/word clinical documents
Client Provider
Operations
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Client Provider Operations
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• Eligibility issues (member, rendering facility, and/or ordering
physician)
• Questions regarding accuracy assessment, accreditation, and/or
credentialing
• Issues experienced during case creation
• Request for an authorization to be resent to the health plan
Provider Relations
Department
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Implementation Document
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Prominence Health Plan Implementation Site:
https://www.evicore.com/implementation/pages/ImplementationResourceDe
tails.aspx?ImpID=76
• CPT code list of the procedures that require prior authorization
• Healthplan quick reference guide
• eviCore clinical guidelines
Provider Enrollment Questions Contact Prominence Health Plan at (775) 770-9300
Coding Guidelines & Program Criteria:
https://www.evicore.com/resources/pages/providers.aspx
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Thank You!