PA/MND Review of Spine Surgery services Questions & Answers
|
|
- Eleanor Eaton
- 6 years ago
- Views:
Transcription
1 PA/MND Review of Spine Surgery services Questions & Answers 1. What is the Musculoskeletal Program? Horizon BCBSNJ has expanded our Pain Management Program with evicore to include Pain Management and Spine Surgery services all of which are now referred to as the Musculoskeletal Program. 2. What services does evicore perform under this expanded collaboration? For Spine Surgery services, evicore provides Utilization Management (UM) review (through either a PA/MND review), First Level UM appeals processing and UM-related Customer Service support. 3. What is the Musculoskeletal Program s claims process for Spine Surgery services? Professional claims for Spine Surgery services will suspend for medical necessity review by evicore. If a PA/MND has not been performed previously, a review will be done in accordance with the clinical guidelines adopted by Horizon BCBSNJ. After the medical necessity review is complete, evicore will return the suspended claim to Horizon BCBSNJ with a recommendation to pay or deny the services. Horizon BCBSNJ will process the claims according to the member s benefits and will continue to handle claim inquiries from both the member and health care professional. Disclaimer: The PA/MND does not supersede member benefits. An authorization does not guarantee payment of services. 4. How does evicore manage Spine Surgery services? evicore reviews PA/MND requests in accordance with the clinical guidelines adopted by Horizon BCBSNJ. 5. What Horizon BCBSNJ products are included in this program? For services rendered in New Jersey, the program will apply to: Horizon HMO Horizon Direct Access (DA) Horizon EPO Indemnity/Traditional OMNIA SM Health Plans Horizon POS Horizon PPO Note: This program does not apply to the Federal Employee Program 1
2 (FEP ), the State Health Benefits Program (SHBP), the School Employees' Health Benefits Program (SEHBP), Medicare Advantage, Medigap, Medicaid or Dual-Eligible Special Needs (DSNP) plans. 6. Are the SHBP and SEHBP participating in the PA/MND review of Spine Surgery services? No. PA/MND review of Spine Surgery services for SHBP/SEHBP members is not part of this program. Health care professionals should call Horizon BCBSNJ s Physician Services at for PA/MND review of Spine Surgery services for SHBP/SEHBP members. 7. What was the effective date for PA/MND of Spine Surgery services? PA/MND of Spine Surgery services was effective November 1, Participating and nonparticipating Horizon BCBSNJ health care professionals must continue to contact evicore directly for PA/MND review requests. 8. Who should be contacted for Pain Management and Spine Surgery procedure codes not managed by evicore? Health care professionals should call Horizon BCBSNJ s Physician Services at Members should call Member Services at the number on the back of their Horizon BCBSNJ identification card for benefit verification. Health care professionals 9. What is the Prior Authorization & Medical Necessity Determination (PA/MND) process for Spine Surgery services? The PA/MND process requires participating and nonparticipating health care professionals to request a review for any proposed course of treatment involving Spine Surgery services. Health care professionals should always contact evicore to obtain a PA/MND prior to rendering services to ensure that the proposed services are medically necessary and therefore will be covered by the plan. If a PA/MND is not obtained, claims may be delayed or denied pending our receipt of the information needed to establish medical necessity. There are three possible outcomes as a result of the PA/MND review: 1. Approved: the complete treatment requested meets the criteria for medical necessity. 2. Partial Approval: only a part of the treatment requested is approved and the remainder is denied. 3. Denied: the complete treatment does not meet clinical criteria and is denied. 2
3 For Inpatient Admissions: PA is required as determined by the member s benefits. For Outpatient Services: PA is required as determined by the member s benefits. Where member benefits do not require a PA, a pre- or post-service MND review will apply. 10. What Spine Surgery services need PA/MND determination? There are specific Spine Surgery services included in this program. Please refer to the List of Spine Surgery Codes subject to medical necessity and appropriateness review posted on the Spine Surgery tab of HorizonBlue.com/musculoskeletal. 11. How often is the Spine Surgery services list updated? The list is updated as necessary. When calling for a PA/MND review request, please check the List of Spine Surgery Codes subject to medical necessity and appropriateness review posted on the Spine Surgery tab of HorizonBlue.com/musculoskeletal. 12. Where are the Spine Surgery guidelines located for members enrolled in plans that have elected to participate in the Musculoskeletal Program? To access the Spine Surgery guidelines evicore uses to make Prior Authorization and Medical Necessity Determination decisions, please visit A link to this information is also included on the Spine Surgery tab of HorizonBlue.com/musculoskeletal. 13. Where are Horizon BCBSNJ s Medical Policy guidelines for Spine Surgery services located for members enrolled in plans that have NOT elected to participate in the Musculoskeletal Program? Horizon BCBSNJ s Medical Policy guidelines for Spine Surgery services for members enrolled in plans that have NOT elected to participate in the Musculoskeletal Program can be found within our online Medical Policy Manual on HorizonBlue.com/medicalpolicy. 14. Where are Spine Surgery services administered for this program? The Spine Surgery services can be administered at an: Inpatient facility Outpatient facility 1 Ambulatory surgical center 1 evicore will not perform PA/MND reviews for Spine Surgery services administered in an observation room or Emergency Room. 3
4 15. How has Horizon BCBSNJ educated health care professionals about the need for PA/MND review of Spine Surgery services? Horizon BCBSNJ has educated health care professionals by: Making an announcement within the News section of HorizonBlue.com/providers (accessible also through NaviNet ) 90 days prior to the program s effective date, which was November 1, This announcement was made on August 1, Posting Musculoskeletal Program information on HorizonBlue.com/musculoskeletal. Information includes additional reference materials such as the Quick Reference Guide (QRG) and List of Spine Surgery services. Making announcements in February 2017 advising health care professionals of the application of medical policies by evicore for members whose plans have elected to participate in the Musculoskeletal Program. If a pre-service PA/MND has not been performed for Spine Surgery services after the effective date of November 1, 2016, those services may be subjected to a post-service MND review prior to claims being paid for those services. 16. Are all Spine Surgery services currently administered by Horizon BCBSNJ included in the new Musculoskeletal Program administered by evicore? The program includes the entire range of Spine Surgery services that are performed in New Jersey by New Jersey participating and nonparticipating health care professionals for in-scope Horizon BCBSNJ fully- and selfinsured products and members. Contiguous county rules will apply only to Horizon BCBSNJ members living in the state of New Jersey that see a health care professional who is contracted with both Horizon BCBSNJ and the plan in which the health care professional is located. Note: ITS Home and ITS Host claims are not included, or are out of scope for the Musculoskeletal Program. However, Horizon BCBSNJ will maintain the administration of medical necessity reviews for the self-insured Administrative Services Only (ASO) employer groups that have not elected to participate in the Musculoskeletal Program. Prior Authorization/Medical Necessity Determination (PA/MND) 17. When should a health care professional obtain a PA/MND? A health care professional should obtain a PA/MND upon determining the patient s treatment plan for a Spine Surgery service. It s important that PA/MND is obtained prior to delivery of the services to ensure coverage. 4
5 Services that are considered not medically necessary when reviewed on a post-service basis will not be covered or reimbursed by Horizon BCBSNJ. 18. How does a health care professional initiate a PA/MND? A rendering or ordering participating health care professional can initiate a PA/MND review by: Visiting evicore s secure website at Calling evicore directly at , Monday through Friday, 7 a.m. to 7 p.m., Eastern Time (ET). Multiple requests can be handled with one call. Urgent requests must be initiated by phone and identified as urgent by calling Representatives are available after hours and on weekends. Nonparticipating health care professionals may initiate a PA/MND review by calling , Monday through Friday, 7 a.m. to 7 p.m., ET. The website is not available to nonparticipating health care professionals or for urgent requests. 19. Will a health care professional be able to initiate a PA/MND review via fax? No. Requests should be initiated online or by phone (see A18). 20. What clinical information is necessary to obtain a PA/MND review? Clinical information required for evicore to make a determination on a particular Spine Surgery service is available at What information should health care professionals have available to initiate the PA/MND review? The health care professional should have the following information: Ordering health care professional name, address and office telephone number Rendering health care professional name, address and office telephone number (if different from ordering health care professional) Rendering facility name, NPI, Tax Identification Number (TIN), address and fax number Member name, date of birth and ID number Anticipated start date of treatment Member height, weight and body surface area Procedure Code and Description Diagnosis (ICD-10 code) Past therapeutic failures including physical therapy, interventional pain procedures, medications and any other conservative treatment 5
6 When applicable, co-surgeon information: name, Federal Tax Identification Number (FTIN), participation status with Horizon BCBSNJ Relevant Diagnostic/Imaging results 22. Will additional information be requested from the health care professional? Yes. Additional information may be requested depending on the Spine Surgery services, such as: Office encounter records, including clinical notes Operative/Procedure report(s) Report(s) of X-rays and high tech imaging; e.g., CT, MRI, nuclear medicine studies and myelography Relevant laboratory test results Pathology reports The health care professional should be prepared to fax the additional necessary documents to evicore s fax at Can the ordering/rendering health care professional request a Peerto-Peer consultation? Yes. The ordering or rendering health care professional may request a Peer-to-Peer consultation after the case has been requested by calling evicore at , Monday through Friday, from 7 a.m. to 7 p.m., ET. A Peer-to-Peer consultation may take place at any time on approved or denied requests. It can be scheduled or done real time. 24. How does a health care professional confirm a PA/MND determination for a patient? The ordering or rendering health care professional (if applicable) will receive a copy of the determination letter. The PA/MND determination may be viewed at or the health care professional can call evicore at and select the Customer Service option. Nonparticipating health care professionals can call for a status of a PA/MND, Monday through Friday from 7 a.m. to 7 p.m., ET. 25. What if evicore does not have all of the necessary information to make a determination on a pre-service PA/MND request? If evicore does not have all of the necessary clinical information to make a determination, the PA/MND request will be pended for clinical review and the ordering or rendering health care professional will be given a case number. evicore will place the case on hold and request the additional clinical information needed to complete the review from the ordering or rendering health care professional s office. 6
7 26. What is the responsibility of the ordering/rendering health care professional? The ordering or rendering health care professional is responsible for obtaining the PA/MND and supplying all of the demographic and clinical information. If a PA/MND is not obtained prior to rendering services, claim payment may be delayed or denied pending completion of a post-service MND review. If the rendering health care professional, who is not the ordering health care professional, calls evicore to initiate a PA/MND, evicore will contact the ordering health care professional to obtain the necessary clinical information. The clinical information must be provided regardless if the ordering and the rendering health care professional are the same. In addition, the rendering health care professional is responsible for indicating if a co-surgeon is required for the requested Spine Surgery services. The health care professional must have the co-surgeon s name, TIN and Horizon BCBSNJ participation status. Refer to the QRG and follow the steps on how to check status of the PA/MND determination on HorizonBlue.com/musculoskeletal. The link is located at the bottom of the Spine Surgery tab. 27. How are health care professionals notified of evicore s PA/MND decision? evicore will 2 health care professionals the approval status of PA/MND requests that are initiated through its web portal. evicore will fax notifications to health care professionals who initiate PA/MND requests by phone, and for those who initiate by web without a valid registered on the web portal. 2 This functionality will only apply to health care professionals and their authorized contacts who have registered a valid on the web portal. Prior to mid-november 2016, evicore will fax its decision. 28. After the decision is rendered, will a determination letter be sent to the health care professional and member? Yes. An approval letter will be sent to the ordering health care professional. A denial letter will be sent to the ordering health care professional, facility and the member. 7
8 29. Can an approved PA/MND determination be changed prior to the expiration date? Yes. A request to change an existing approved PA/MND determination can be submitted by calling evicore at The clinical staff will review the request and render a decision. evicore would not typically update an authorization after the service has been performed. They will review it prior to the expiration date. It must meet medical necessity criteria to update an authorization. 30. Are clinical trials part of this program? No. Clinical trials are not a part of this program. Please call Horizon BCBSNJ s Complex Case Management department at for clinical trials. 31. What is the time frame for evicore to render a decision for PA/MND? Non-urgent requests will be completed as soon as possible based on the urgency of the case, but no later than three business days from receipt of all required clinical information. Urgent requests will be completed as soon as possible based on the urgency of the case, but no later than 24 hours from receipt of the request. 32. Does a health care professional need a username and password to access evicore s application to request PA/MND? Yes. The health care professional should refer to the online QRG for instructions on how to obtain a username and password. The QRG is available on the Spine Surgery tab of HorizonBlue.com/musculoskeletal. 33. What is the difference between a case number and a PA/MND number? The case number is all numeric and assigned at the initiation of a request. A PA/MND number is not assigned until a final determination is made. 34. Is there a way to verify if a PA or MND number has been assigned to a request? Yes. Physicians or other health care professionals can logon to and click Authorization Lookup. Select the member s Health Plan and enter the Health care professional ID, TIN, Office or Health care professional Name. These are required fields for this search. Enter the patient s ID and Date of Birth and click Search. 8
9 35. Does a PA/MND number expire? Yes. An approved PA/MND is good for 45 days. Physicians can log in to and click Authorization Lookup for individual case details. 36. Is the PA/MND valid for the entire inpatient and outpatient stay? The PA/MND from evicore is valid for the eligible services relative to and occurred/rendered in the: Inpatient facility Outpatient facility Ambulatory surgical center Claims Disclaimer: The PA/MND does not supersede member benefits. An authorization does not guarantee payment of services. 37. How will this new program affect claims submission? Claims should be submitted in the same manner as before. Pre-service PA/MND review is recommended to avoid claims processing delays. 38. What happens to the claim if a PA/MND was not requested prior to the services being rendered? If a claim is submitted without obtaining a pre-service PA/MND, then the processing of the claim will be delayed until a PA/MND review can be performed and medical necessity is established. 39. What is required to expedite claims processing? To expedite claims processing, the following information is needed: An approved PA/MND determination number The appropriate HCPCS code for the specific procedure being billed The itemized date(s) of service 40. What happens if evicore does not receive the necessary information to make the determination on a post-service MND request? If medical records are not received in the required time frame, your claim will be denied and will remain denied until the requested clinical documentation is received. One fax attempt will be made by evicore to contact the ordering health care professional to obtain the necessary clinical information. If evicore is unsuccessful in obtaining the necessary clinical information, then evicore will request the necessary clinical information in writing and the health care professional will be given 25 days to submit the requested information. 9
10 Appeals 41. How does a health care professional dispute a PA/MND denial? Information on how to appeal a denial will be provided in the denial letter issued by evicore. Generally, a health care professional may dispute a denial that was based on medical necessity as follows: For members in plans that are part in the Musculoskeletal Program, health care professionals should call evicore at Submit written appeals to: evicore healthcare Attn: Appeals Coordinator 400 Buckwalter Place Boulevard Bluffton, SC Phone: Fax: How does a health care professional dispute a denial that is not related to a PA/MND? A health care professional may dispute a denied claims determination that is not related to a PA/MND (a decision not based on medical judgment) by calling Horizon BCBSNJ at: Physician Services: Facility Centralized Service Center: Members can call Member Services at BLUE (2583) or the number listed on the back of their member identification cards. 43. Who can a health care professional contact for more information about a PA/MND appeal they submitted? For an appeal involving a PA/MND, call evicore at For a claim appeal not involving medical judgment, call Horizon BCBSNJ s Physician Services at
Medical Injectables Program
Medical Injectables Program Quick Reference Guide HorizonBlue.com Table of Contents Introduction... 3 Contact Magellan Rx Management... 3 Medical Injectables MNAR List... 4 Basic Information Required for
More informationHIGHMARK RADIATION THERAPY AUTHORIZATION PROGRAM FREQUENTLY ASKED QUESTIONS
HIGHMARK RADIATION THERAPY AUTHORIZATION PROGRAM FREQUENTLY ASKED QUESTIONS Revised: April 1, 2015 GENERAL POLICIES AND PROCEDURES Q1. Can you provide me with an overview of this program? A1. Highmark
More informationHealth Alliance. Utilization Management Changes Overview. Maxine Wallner Director Provider Services. February 2017
Health Alliance Utilization Management Changes Overview February 2017 Maxine Wallner Director Provider Services Agenda Decision Overview Utilization Management Program Changes Expansions and modifications
More informationCareCore National & Alliance Provider Training Material
EVIDENCE-BASED HEALTHCARE SOLUTIONS CareCore National & Alliance Provider Training Material Prepared for: March 6, 2014 Contents CareCore National... 3 Alliance and CareCore National Partnership... 4 Radiology
More informationHealthChoice Radiology Management. March 1, 2010
HealthChoice Radiology Management March 1, 2010 Introduction Acting on behalf of our Medicaid customers in Maryland (HealthChoice), UnitedHealthcare has worked with external physician advisory groups to
More informationBCBSNC Best Practices
BCBSNC Best Practices Thank you for attending today! We value your commitment of caring for our members your patients and our shared goals for their improved health An independent licensee of the Blue
More informationevicore healthcare... 1 Chiropractic Services Precertification Requirements... 1 Treatment Plans... 2 When to Submit the Treatment Plan...
Contents Obtaining Precertification... 1 evicore healthcare... 1 Chiropractic Services Precertification Requirements... 1 Treatment Plans... 2 When to Submit the Treatment Plan... 3 Date Extensions on
More informationApplied Behavior Analysis (ABA) Provider Update March 2015
Applied Behavior Analysis (ABA) Provider Update March 2015 Objectives Overview of Horizon Blue Cross Blue Shield of New Jersey Behavioral Health Program AMA CPT Code Changes Impacted CPT Codes with New
More informationRE: Important Information Regarding Prior Authorization for High Tech Imaging Services
Name Address City, St Zip RE: Important Information Regarding Prior Authorization for High Tech Imaging Services Dear Provider: Blue Cross and Blue Shield of Louisiana and HMO of Louisiana, Inc., (HMOLA),
More informationIntroduction: Physical Therapy Utilization Management Program
UM Category A Guide Introduction: Physical Therapy Utilization Management Program The Physical Therapy Utilization Management (UM) program has two primary objectives. First is to bring transparency and
More informationYour Retired Health Benefits and Medicare Part A & B
HR-0116-0317 Fact Sheet #23 A PUBLICATION OF THE NEW JERSEY DIVISION OF PENSIONS AND BENEFITS Your Retired Health Benefits and Medicare Part A & B State Health Benefits Program School Employees Health
More informationHOME HEALTH CARE TABLE OF CONTENTS. OVERVIEW TRANSITIONAL... CARE... SERVICES . MEMBERS... MANAGED... BY... EVICORE
TABLE OF CONTENTS. OVERVIEW............................................................................................. 452..... TRANSITIONAL................. CARE...... SERVICES......................................................................
More informationBlue Choice PPO SM Provider Manual - Preauthorization
In this Section Blue Choice PPO SM Provider Manual - The following topics are covered in this section. Topic Page Overview E 3 What Requires E 3 evicore Program E 3 Responsibility for E 3 When to Preauthorize
More informationPrecertification Tips & Tools
Working with Anthem Subject Specific Webinar Series Precertification Tips & Tools Access to Audio Portion of Conference: Dial-In Number: 877-497-8913 Conference Code: 1322819809# Please Mute Your Phone
More informationDean Health Plan Physical Medicine Overview
Dean Health Plan Physical Medicine Overview Provider Training / Presented by: Leta Genasci Above and throughout this document, NIA Magellan refers to National Imaging Associates, Inc. Dean Health Plan
More informationUtilization Review Determination Time Frames
Utilization Review Time Frames The purpose of this chart is to reference utilization review (UR) determination time frames. It is not meant to completely outline the UR determination process. Refer to
More informationHMSA Physical and Occupational Therapy Utilization Management Guide
HMSA Physical and Occupational Therapy Utilization Management Guide Published November 1, 2010 An Independent Licensee of the Blue Cross and Blue Shield Association Landmark's provider materials are available
More informationNational Imaging Associates, Inc. (NIA) 1 Medical Specialty Solutions
National Imaging Associates, Inc. (NIA) 1 Medical Specialty Solutions Provider Training/Presented by: Name: Kevin Apgar 1 National Imaging Associates, Inc. (NIA) is a subsidiary of Magellan Healthcare,
More informationevicore healthcare Program Reimplementation Effective June 1, 2015
evicore healthcare Program Reimplementation Effective June 1, 2015 Reimplementation Plans Effective June 1, 2015, Network Health will reinstate the prior authorization requirements for the following specialty
More informationMagellan Healthcare 1 Frequently Asked Questions (FAQ s) For Magellan Complete Care of Florida Providers
Magellan Healthcare 1 Frequently Asked Questions (FAQ s) For Magellan Complete Care of Florida Providers Question GENERAL Why did Magellan Complete Care implement a Medical Specialty Solutions Program?
More informationMedicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) Provider Transition Orientation December 1, 2015
Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) Provider Transition Orientation December 1, 2015 PWP-9002-15 A Division of Health Care Service Corporation, a Mutual
More informationCHAPTER 3: EXECUTIVE SUMMARY
INDIANA PROVIDER MANUAL EXECUTIVE SUMMARY Indiana Family and Social Services Administration (FSSA) contracts with Anthem Insurance Companies, Inc. (dba Anthem Blue Cross and Blue Shield) for the provision
More informationProvider Website Overview
Provider Website Overview Prepared for Physical Therapy Association of Washington May 11, 2017 Stephanie Cole Healthcare Implementation Manager Agenda Introduction Quick Facts Live Demo Benefits Code checks
More informationMolina Healthcare MyCare Ohio Prior Authorizations
Molina Healthcare MyCare Ohio Prior Authorizations Agenda Eligibility Medicare Passive Enrollment Transition of Care Definition Submission Time Frame Standard vs. Urgent How to Submit a Prior Authorization
More informationPrecertification Frequently Asked Questions
Precertification Frequently Asked Questions 1. Which HMSA plans require precertification from Landmark? 2. How do I submit a Treatment Plan? 3. How do I print a copy of my completed e Form? 4. How do I
More informationMagellan Healthcare 1 Frequently Asked Questions (FAQ s) For Magellan Complete Care of Virginia Providers
Magellan Healthcare 1 Frequently Asked Questions (FAQ s) For Magellan Complete Care of Virginia Providers Question GENERAL Why is Magellan Complete Care of Virginia implementing a Medical Specialty Solutions
More informationEVIDENCE-BASED HEALTHCARE SOLUTIONS. CareCore National. Frequently Asked Questions Prepared for. Prepared for. October 23, 2009
EVIDENCE-BASED HEALTHCARE SOLUTIONS CareCore National Musculoskeletal CARECORE NATIONAL Management RADIOLOGY Program Physical BENEFIT Medicine MANAGEMENT and Therapy PROPOSAL Prepared for Prepared for
More informationBlue Care Network Physical & Occupational Therapy Utilization Management Guide
Blue Care Network Physical & Occupational Therapy Utilization Management Guide (Also applies to physical medicine services by chiropractors) January 2016 Table of Contents Program Overview... 1 Physical
More informationMagellan Complete Care of Virginia Musculoskeletal Care Management (MSK)Program
Magellan Healthcare 1 Magellan Complete Care of Virginia Musculoskeletal Care Management (MSK)Program 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. Magellan Healthcare
More informationUTILIZATION MANAGEMENT AND CARE COORDINATION Section 8
Overview The focus of WellCare s Utilization Management (UM) Program is to provide members access to quality care and to monitor the appropriate utilization of services. WellCare s UM Program has five
More informationAetna. NOMNC Letter -- SNF needs to fax to NOMNC Fax
FINAL APPROVED 3/17/2015 Aetna Optum has contracted with Aetna Better Health to provide NP model of care during a nursing facility event and has assumed responsibility for obtaining service authorizations
More informationHPHConnect for Providers. Habilitative & Rehabilitative Therapies Notifications User Guide
HPHConnect for Providers Habilitative & Rehabilitative Therapies Notifications User Guide December 2017 HPHCONNECT HOME REHABILITATIVE THERAPIES NOTIFICATIONS USER GUIDE Table of Contents A. HABILITATIVE
More informationAMBULATORY SURGERY FACILITY GENERAL INFORMATION
AMBULATORY SURGERY FACILITY GENERAL INFORMATION I. BCBSM s Ambulatory Surgery Facility Programs Traditional BCBSM s Traditional Ambulatory Surgery Facility Program includes all facilities that are licensed
More informationMississippi Medicaid Inpatient Services Provider Manual
Mississippi Medicaid Inpatient Services Provider Manual Effective Date: November 2015 Revised: June 2016 Inpatient Services Provider Manual Introduction eqhealth Solutions (eqhealth) is the Utilization
More informationManaged Care Referrals and Authorizations (Central Region Products)
In this section Page Overview of Referrals and Authorizations 10.1 Referrals 10.1! Referrals: SelectBlue only 10.1! Definition of referrals 10.1! Services not requiring a referral 10.1! Who can issue a
More informationMedical Management Program
Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent Fraud, Waste and Abuse in its programs. The Molina
More informationABOUT FLORIDA MEDICAID
Section I Introduction About eqhealth Solutions ABOUT FLORIDA MEDICAID THE FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION The Florida Agency for Health Care Administration (AHCA or Agency) is the single
More informationMagellan Healthcare 1 Medical Specialty Solutions
Magellan Healthcare 1 Medical Specialty Solutions Horizon NJ Health 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. Magellan Healthcare Training 2 Magellan Healthcare Agenda
More informationSection 7. Medical Management Program
Section 7. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.
More informationConnecticut Medical Assistance Program Refresher for Hospice Providers. Presented by The Department of Social Services & HP for Billing Providers
Connecticut Medical Assistance Program Refresher for Hospice Providers Presented by The Department of Social Services & HP for Billing Providers 1 Training Topics Hospice Agenda HIPAA 5010 Hospice Form
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 08/15/12 REPLACED: 07/01/11 CHAPTER 25: HOSPITAL SERVICES SECTION 25.3: OUTPATIENT SERVICES PAGE(S) 11
OUTPATIENT SERVICES Outpatient hospital services are defined as diagnostic and therapeutic services rendered under the direction of a physician or dentist to an outpatient in an enrolled, licensed and
More informationChapter 4 Health Care Management Unit 4: Denials, Grievances and Appeals
Chapter 4 Health Care Management Unit 4: Denials, Grievances and Appeals In This Unit Topic See Page Unit 4: Denials, Grievances And Appeals Member Grievances/Appeals 2 Filing a Grievance/Appeal on the
More informationHMSA Physical and Occupational Therapy Utilization Management Authorization Guide
HMSA Physical and Occupational Therapy Utilization Management Authorization Guide Published Landmark's provider materials are available online at www.landmarkhealthcare.com. The online Physical and Occupational
More informationProvider Manual. Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) TNGA Provider Manual (3)
Provider Manual Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) TNGA Provider Manual (3) Table of Contents Table of Contents... 2 Welcome!... 3 Important Contact Information...
More informationJoining Passport Health Plan. Welcome IMPACT Plus Providers
Joining Passport Health Plan Welcome IMPACT Plus Providers Agenda Passport Behavioral Health Services Overview Steps to Joining Passport Health Plan s Network Getting a Medicaid Number Enrolling in the
More informationManaged Long Term Services and Supports (MLTSS)
Managed Long Term Services and Supports (MLTSS) George L. Ingram Director, Network Contracting and Servicing 1 Effective July 1, 2014 What is MLTSS? Transition from fee-for-service model to Managed Medicaid
More informationHome address City State ZIP Code
Member Appeal Form Date of Request PATIENT INFORMATION Last name First name MI Member ID # Date of birth (MM/DD/YYYY) Name of representative pursuing appeal, if different from above (See instructions,
More information4 Professional Provider Responsibilities Overview
Blues Provider Reference Manual Overview Introduction A provider is a duly licensed facility, physician or other professional authorized to furnish health care services within the scope of licensure. A
More informationColoradoPAR Program Durable Medical Equipment. August 2015
ColoradoPAR Program Durable Medical Equipment August 2015 Agenda Introduction to eqhealth Solutions Scope of Services Overview of the PAR process eqsuite Contacts and resources at eqhealth Solutions Key
More informationSection 4 - Referrals and Authorizations: UM Department
Section 4 - Referrals and Authorizations: UM Department Primary Care Referral Process 1 Referrals to In-Network Specialists 1 Referrals to Out-Of-Network Specialists 2 Consultation Referral Forms 2 Consultation
More informationDear Valued Network Physician:
, Radiation Oncology As announced on July 1, 009 on OxfordHealth.com and UnitedHealthcareOnline.com, medical coverage reviews for radiation therapy
More informationABOUT AHCA AND FLORIDA MEDICAID
Section I Introduction About AHCA and Florida Medicaid ABOUT AHCA AND FLORIDA MEDICAID THE FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION The Florida Agency for Health Care Administration (AHCA or Agency)
More informationAetna/Coventry Pennsylvania and West Virginia Physical Medicine Overview for Providers
Aetna/Coventry Pennsylvania and West Virginia Physical Medicine Overview for Providers Aetna Physical Medicine Overview What: When: Who: Aetna will initiate a Utilization Management Prior Authorization
More information2017 Qualified Health Plans Educational Webinars. Frequently Asked Questions (FAQ) from sessions held week of: 12/19/ /23/2016
2017 Qualified Health Plans Educational Webinars Frequently Asked Questions (FAQ) from sessions held week of: 12/19/2016 12/23/2016 1. You have referred us to the Blue Cross of Idaho website to check the
More informationConnecticut Medical Assistance Program Refresher for Hospice Providers. Presented by The Department of Social Services & HP for Billing Providers
Connecticut Medical Assistance Program Refresher for Hospice Providers Presented by The Department of Social Services & HP for Billing Providers 1 Hospice Agenda Overview Forms Fee Schedule/Reimbursement
More informationAdvanced Imaging and Cardiac Procedures Prior Authorization Update
Advanced Imaging and Cardiac Procedures Prior Authorization Update Presented by: Laurie Kim Director, Provider Relations and Account Management Hawai`i HMSA Provider/Staff Training Webinar August 11, 2016
More informationCorCare PPO Provider Manual. Updated 12/19/2016
CorCare PPO Provider Manual 2017 Updated 12/19/2016 TABLE OF CONTENTS TABLE OF CONTENTS 1. Summary of Procedures, Resources, Claims Submissions... 3 2. Claims Completion... 4 3. Prepayment and Balanced
More informationSECTION 9 Referrals and Authorizations
SECTION 9 Referrals and Authorizations General Information The PAMF Utilization Management (UM) Program is carried out by the Managed Care department. The UM Program is designed to ensure that all Members
More informationNaviNet Authorizations transaction: Frequently asked questions
NaviNet Authorizations transaction: Frequently asked questions 1 of 4 10/30/2017 These frequently asked questions (FAQs) were developed to assist you in navigating the new Authorizations transaction on
More informationState of Alaska Department of Health and Social Services. Community-Based Youth Residential Behavioral Health Services Review Provider Manual
State of Alaska Department of Health and Social Services Community-Based Youth Residential Behavioral Health Services Review Provider Manual February 2018 TABLE OF CONTENTS Section 1: Qualis Health Care
More informationReimbursement Policy. Subject: Consultations Effective Date: 05/01/05
Reimbursement Policy Subject: Consultations Effective Date: 05/01/05 Committee Approval Obtained: 06/06/16 Section: Evaluation and Management *****The most current version of the Reimbursement Policies
More informationMOLINA HEALTHCARE MEDICAID PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 6/1/2018
MOLINA HEALTHCARE MEDICAID PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 6/1/2018 THIS PRIOR AUTHORIZATION/PRE-SERVICE GUIDE APPLIES TO ALL MOLINA HEALTHCARE MEDICAID MEMBERS ONLY REFER TO MOLINA
More informationBlue Shield of California
An independent member of the Blue Shield Association City of San Jose Custom ASO PPO 100 90/70 Active Employees Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage
More informationMississippi Medicaid Hospice Services Provider Manual
Mississippi Medicaid Hospice Services Provider Manual Effective: January 2011 Revised: January 2017 Table of Contents I. Introduction II. Frequently Used Terms III. Getting Started Helpful Tips A. Before
More informationDiagnostic Imaging Management
Diagnostic Imaging Management Provider Office Staff Training Updated May 2012 An independent licensee of the Blue Cross and Blue Shield Association. U7430b, 2/11 Diagnostic Imaging Management Program
More informationNIA Magellan 1 Frequently Asked Questions (FAQ s) For Coventry Health Care of Illinois Providers
NIA Magellan 1 Frequently Asked Questions (FAQ s) For Coventry Health Care of Illinois Providers Question GENERAL Why is Coventry Health Care of Illinois implementing an outpatient imaging program? Answer
More informationINFORMATION ABOUT YOUR OXFORD COVERAGE REIMBURSEMENT PART I OXFORD HEALTH PLANS OXFORD HEALTH PLANS (NJ), INC.
OXFORD HEALTH PLANS (NJ), INC. INFORMATION ABOUT YOUR OXFORD COVERAGE PART I REIMBURSEMENT Overview of Provider Reimbursement Methodologies Generally, Oxford pays Network Providers on a fee-for-service
More informationBlue Medicare Private-Fee-For-Service SM (PFFS) 2008 Medicare Advantage Terms and Conditions
Blue Medicare Private-Fee-For-Service SM (PFFS) 2008 Medicare Advantage Terms and Conditions Medicare Advantage Table of Contents Page Plan Highlights...2 Provider Participation The Deeming Process...2
More informationRe: Non-participation in the new Horizon Medicare Blue Patient-Centered w/rx (HMO) product
Three Penn Plaza East Newark, NJ 07105-2200 HorizonBlue.com October 2014 Re: Non-participation in the new Horizon Medicare Blue Patient-Centered w/rx (HMO) product
More informationNIA Magellan 1 Medical Specialty Solutions
NIA Magellan 1 Medical Specialty Solutions CeltiCare of Massachusetts Health Provider Training 1 - NIA Magellan refers to National Imaging Associates, Inc. NIA Magellan Training Program 2 NIA Magellan
More informationTABLE OF CONTENTS. Therapy Services Provider Manual Table of Contents
Table of Contents TABLE OF CONTENTS Table of Contents...1 About AHCA...2 About eqhealth Solutions...2 Accessibility and Contact Information...5 Review Requirements and Submitting PA Requests...9 First
More informationPassport Advantage Provider Manual Section 5.0 Utilization Management
Passport Advantage Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria 5.3 Prior Authorization Requirements 5.4 Organization Determinations
More informationState of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue.
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Earl Ray Tomblin Governor Rocco S. Fucillo Cabinet Secretary November 20,
More informationKDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance. UM Retrospective Review Services.
KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance UM Retrospective Review Services Provider Manual August 2017 This page intentionally blank Table of Contents KDHE-DHCF:
More informationKentucky Spirit Health Plan Provider Training Program
Kentucky Spirit Health Plan Provider Training Program Provider Training Program Agenda Welcome and Opening Remarks About NIA The Provider Partnership The Program Components The Provider Assessment Program
More informationBCBSIL iexchange Reference Guide
BCBSIL iexchange Reference Guide April 2010 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Table of
More informationINPATIENT Provider Utilization Review and Quality Assurance Manual. Short Term Acute Care
INPATIENT Provider Utilization Review and Quality Assurance Manual Short Term Acute Care Revised December 15, 2014 Table of Contents Section A: Overview... 2 General Information... 3 1. About eqhealth
More informationHospital Refresher Workshop. Presented by The Department of Social Services & HP Enterprise Services
Hospital Refresher Workshop Presented by The Department of Social Services & HP Enterprise Services 1 Training Topics Provider Bulletins Outpatient Claim Billing Changes Explanation of Benefit Codes Web
More informationOverview of eqsuite. 24/7 accessibility to submit review requests. A helpline module for Providers to submit queries.
Multispecialty 2017 Overview of eqsuite 24/7 accessibility to submit review requests Electronic submission and Provider Alerts A helpline module for Providers to submit queries. System access control for
More informationKeystone First Provider Training
Keystone First Provider Training NIA Program Agenda Introduction to National Imaging Associates (NIA) Our Program 1. Authorization Process 2. Other Program Components 3. Provider Tools and Contact Information
More informationChapter 2 Provider Responsibilities Unit 6: Behavioral Health Care Specialists
Chapter 2 Provider Responsibilities Unit 6: Health Care Specialists In This Unit Unit 6: Health Care Specialists General Information 2 Highmark s Health Programs 4 Accessibility Standards For Health Providers
More informationMolina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)
Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience
More informationCONTRACT YEAR 2011 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT
CONTRACT YEAR 2011 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT Table of Contents 1. Introduction 2. When a provider is deemed to accept Flexi Blue PFFS terms and
More informationNational Imaging Associates, Inc. (NIA) Medical Specialty Solutions
National Imaging Associates, Inc. (NIA) Medical Specialty Solutions NIA Program Agenda Introduction Our Program 1. Expanded Program 2. Authorization Process 3. Clinical Validation of Records 4. Other Program
More informationReimbursement Policy (EXTERNAL)
Subject: Consultations Reimbursement Policy (EXTERNAL) Effective Date: 01/01/15 Committee Approval Obtained: 06/06/16 Section: E&M/Medicine ***** The most current version of our reimbursement policies
More informationLong Term Care Nursing Facility Resource Guide
Long Term Care Nursing Facility Resource Guide September 2014 Table of Contents Section 1: Introduction and Overview Introduction... 4 Purpose and Organization of Long Term Care Nursing Facility Resource
More informationTRICARE West Region Authorizations and Referrals
TRICARE West Region Authorizations and Referrals March 2018 last updated March 19, 2018 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. 1 Welcome
More informationNHPNet Home Health Care Authorization User Guide
NHPNet Home Health Care Authorization User Guide February 22, 2017 v 1.10 nhp.org Introduction NHPNet is a web-based tool used to submit referrals for specialist visits and authorization requests for specific
More informationDIVISION OF MEDICAID Provider Workshop 2016 MSCAN & CHIP
DIVISION OF MEDICAID Provider Workshop 2016 MSCAN & CHIP Magnolia Health MississippiCAN Overview 2011 30,000 Members December 2012 77,000 Members December 2014 98,000 Members January 2015 115,000 Members
More informationParticipating Provider Manual
Participating Provider Manual Revised November 2012 TABLE OF CONTENTS 1. INTRODUCTION Page 5 Psychcare, LLC s Management Team Mission statement Company background Accreditations Provider network 2. MEMBER
More informationAmerigroup Kansas Provider Training Program
Amerigroup Kansas Provider Training Program Agenda About NIA The Provider Partnership The Program Components How the Program Works: The Precertification Process The Precertification Appeals Process The
More informationAdvanced Diagnostic Imaging (ADI)
Advanced Diagnostic Imaging (ADI) 2016 1 eqhealth Solutions 2 Overview of eqsuite» 24/7 accessibility to submit review requests to eqhealth via web.» Secure transmission protocols that are HIPPA security
More informationGeneral Who is National Imaging Associates, Inc. (NIA)?
National Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For Managed Health Services (MHS) Providers Post Service Therapy Review Program Question Answer General Who is National Imaging
More informationState of Montana. Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES
State of Montana Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES FOR UTILIZATION MANAGEMENT January 31, 2013 Children s Mental Health
More informationAn EPO Employee and Retiree Medical Plan...
An EPO Employee and Retiree Medical Plan... Member Handbook...with PPO Benefit Option The benefits and service you love. Plus. IMPORTANT CONTACT INFORMATION PLAN INFORMATION AND MEMBER SERVICES Office
More informationNIA Magellan 1 Medical Specialty Solutions
NIA Magellan 1 Medical Specialty Solutions Provider Training 1 NIA Magellan refers to National Imaging Associates, Inc. NIA Magellan Training Program 2 NIA Magellan Program Agenda Introduction to NIA Magellan
More informationPrecertification: Overview
Precertification: Overview Introduction Precertification determines whether medical services are: Medically Necessary or Experimental/Investigational Provided in the appropriate setting or at the appropriate
More informationReimbursement Policy. Subject: Consultations Committee Approval Obtained: Effective Date: 11/01/13
Reimbursement Policy Subject: Committee Approval Obtained: Effective Date: 11/01/13 Section: E&M/Medicine 06/06/16 ***** The most current version of our reimbursement policies can be found on our provider
More informationState of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Williamson, WV 25661
Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Williamson, WV 25661 Rocco S. Fucillo Cabinet Secretary
More informationMedical Management. G.2 At a Glance. G.3 Procedures Requiring Prior Authorization. G.5 How to Contact or Notify Medical Management
G.2 At a Glance G.3 Procedures Requiring Prior Authorization G.5 How to Contact or Notify Medical Management G.6 When to Notify Medical Management G.11 Case Management Services G.14 Special Needs Services
More information