CareCore National & Alliance Provider Training Material

Transcription

1 EVIDENCE-BASED HEALTHCARE SOLUTIONS CareCore National & Alliance Provider Training Material Prepared for: March 6, 2014

2 Contents CareCore National... 3 Alliance and CareCore National Partnership... 4 Radiology Management Services... 5 Cardiology Management Program... Error! Bookmark not defined. Medical Oncology Management Program... Error! Bookmark not defined. Musculoskeletal Management Program... Error! Bookmark not defined. Molecular & Genetic Lab Management Program... Error! Bookmark not defined. Sleep Management Program... Error! Bookmark not defined. Radiation Therapy Management Program... Error! Bookmark not defined. Obtaining a Prior Authorization... Error! Bookmark not defined. Phone Authorization... Error! Bookmark not defined. Web Authorization... Error! Bookmark not defined. Registering For Provider Web Portal Access... 7 Expedited Case Processing... 10

3 CareCore National Our Specialty Benefit Management programs include customized radiology, cardiology, oncology, musculoskeletal management, molecular and genetic laboratory management, sleep, and radiation therapy services. Our staff of board-certified physicians are involved at every step of the management process including the research and development of clinical criteria and quality management programs. We are dedicated to maintaining the most current, clinically relevant evidence-based medical necessity criteria when determining the appropriate utilization of radiology, cardiology and oncology services. As a specialty benefit management company, we manage the quality and use of outpatient diagnostic and cardiac imaging, cardiac implantable devices, oncology drugs and therapeutic agents, radiation therapy, sleep, pain and lab services. Our goal is to make sure that every treatment and test is medically necessary and absolutely appropriate for the individual patient. CareCore National is a nationally recognized, physician founded benefit management services corporation CareCore is URAC accredited, NCQA certified and Cybertrust Secured Our Clinical Philosophy Patient-centered care founded on best available evidence Functionally oriented and measurable treatment programs Focus on skilled therapy interventions Empower patient independence Certain practice variation cannot be explained or justified Our Program Goals Promote evidence-based practice Provide evidence-based guidelines to support authorization decisions and educate practitioners Decrease or eliminate unexplained practice variation and unnecessary visits Keep costs under control so members can continue to receive quality care, skilled services

4 Alliance and CareCore National Partnership The Alliance will begin contracting with a company called CareCore National in 2014 to pre-authorize specific outpatient diagnostic imaging procedures. With your cooperation, Alliance s partnership with CareCore National will help members and your patients to improve the quality and appropriateness of these services by reducing variations that exists in the utilization of imaging services. Beginning on March 18, 2014, Alliance will begin prior authorization requirements for their members to include the following outpatient procedures: Radiology Management Services (MRI/ MRA/ CT/ PET/Nuclear Medicine) Additional information regarding each program will be posted on their website at Please check back for regular updates. Beginning March 18, 2014, physicians may request a prior authorization for services with dates of service on or after April 1, 2014 by contacting CareCore using one of the following methods: Phone: Online:

5 Radiology Management Services CareCore National s Radiology Management Program offers a scope of services to effectively manage outpatient advanced radiology benefits by targeting utilization and quality. Radiology Management Program Components Components of the Radiology Management Program are described below: MRI CT (including contrast and 3DI) PET Nuclear Medicine Pre-certification Requirements This program is applicable to services provided in the following settings: Ambulatory Surgery Centers, Free- Standing Radiology Facilities, Outpatient Facilities, Physician Offices, and Inpatient Facilities. CareCore National does not require precertification if the service is performed in: an Emergency Room/Department, Observation Unity, or Urgent Care Facility. Member benefits include: Cost and Quality transparency and education Access to high quality, cost-effective facilities Personalized outreach with facility selection and appointment scheduling assistance Allows for member choice and patient driven care

6 Step by Step Instructions Logon with your User ID and password on CareCoreNational.com Select Request a Clinical Certification to start the process: 1) Patient Selection Select Payer Enter Member ID, Group Number, Name, and DOB Select Eligibility Lookup Click Select to locate patient Verify the test has not already been ordered Select Continue 2) Referring Provider Selection Select the referring physician from the list provided Select the physician s Location Enter the Contact name, verify Physician s phone and fax numbers, enter extension if applicable, and select Continue Select the Program for Certification Select Continue 3) Procedure Selection Enter the Expected Procedure Date, Service, and ICD-9 Code (code or description) Select Lookup then select the ICD-9 code from the list Verify the information and select Continue 4) Site Selection Enter the Site Name, City, or TIN and select Lookup Site Select appropriate site from the list Verify the selected site and select Continue Check the Acknowledgement box stating that the information that has been provided is accurate and all information known has been supplied. Select Submit Case.

7 Registering For Provider Web Portal Access Enter into the address bar in your web browser. Choose Register under the Ordering Physician Login section in the middle of the page. Registration Requirements After being directed to the Register for a User Name Web page, there will be steps provided on how to register for a user name and password. 1. Enter the following information as the user information Contact Name Address Address Phone 2. Enter the following information for practitioner information Tax ID NPI Provider Numbers assigned by each health plan Register for a User Name This page will prompt you to enter the following information: User Type: Referring, Rendering Provider or Physical Medicine Provider Office/Facility Name: Primary Contact name: Address: Confirm Address: Mailing Address: City/ State/ Zip: Phone Number Fax Number:

8 Add Providers When the Add Physician Web page is displayed, you will need to select Alameda Health Alliance and insert the provider s ID or NPI to add the provider. If there are matches on the information you provided: Select the correct location. Additional locations may be added, but the search will have to be performed again.

9 Manage Your Account In the Manage Your Account Section of the Provider Web Portal, you may check: Contact information Change your password Edit your account Add/Remove Physicians from the practice Registration Complete Once you have selected providers for your account the registration is complete. The user may use the site immediately and submit a prior authorization request. To submit a prior authorization request online, simply: Enter into your web browser address bar Enter username and password into the ordering physician login fields Select the arrow to the right to go!

10 Expedited Case Processing In order to expedite the processing of your request, please have the following available when you initiate a case: 1. Ordering physician name, office phone, mailing address, fax number and NPI number 2. Referring physician contact name 3. Patient name, date of birth, and health plan member ID number 4. Requested procedure code (ICD 9, CPT, name of procedure) 5. Reason for request, such as: Diagnoses Rule out disorder 6. Conservative treatment (and duration) patient has already completed, such as: Physical therapy Medications Exact start and end dates 7. List of symptoms and their duration 8. Please have the following materials available to reference: Any pertinent clinical testing or procedures, including labs, etc X-rays, ultrasounds, CTs, MRIs, etc Anticipated date of service (if known)