Magellan Healthcare 1 Medical Specialty Solutions

Transcription

1 Magellan Healthcare 1 Medical Specialty Solutions Horizon NJ Health 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc.

2 Magellan Healthcare Training 2

3 Magellan Healthcare Agenda Introduction to Magellan Healthcare Our 1. Authorization Process 2. Other Components 3. Provider Tools and Contact Information Questions and Answers 3

4 A Unique Vision of Care As the nation s leading specialty health care management company, we deliver comprehensive and innovative solutions to improve quality outcomes and optimize cost of care. >20% clinical disapproval rates 4

5 Magellan Healthcare Highlights Magellan Healthcare Facts Industry Presence Clinical Leadership Product Portfolio Providing Client Solutions since 1995 Magellan Acquisition (2006) Columbia, MD with 700 National Magellan Healthcare Employees Business supported by two National Call Operational Centers 79 Health Plan Clients serving 26.67M National Lives 15.94M Commercial; 1.28M Medicare; 9.46M Medicaid 36 states Strong panel of internal Clinical leaders client consultation; clinical framework Supplemented by broad panel of external clinical experts as consultants (for guidelines) Advanced Diagnostic Imaging Cardiac Solutions Radiation Oncology Ob Ultrasound Genetic Testing Musculoskeletal Management (Surgery/IPM) Chiropractic Care, Speech Therapy, Physical and Occupational Therapies Sleep Management Emergency Department Clinical Decision Support Provider Profiling & Practice Management Analysis URAC Accreditation & NCQA Certified 5

6 Magellan Healthcare s Prior Authorization Effective 12/1/2013, Horizon NJ Expanded its Relationship Only non-emergent procedures performed in an outpatient setting require authorization with Magellan Healthcare Procedures Requiring Prior Authorization In addition to the management of CTs, MRs PET and Nuclear Cardiology/Nuclear Stress MPI, Prior authorization from Magellan Healthcare for the following non-emergent outpatient services: Select Non-Advanced Radiology Procedures Non OB/GYN ultrasounds Stress Echocardiography Echocardiography Cardiac Computed Tomography Angiography (CCTA) Cardiac Catheterization Cardiac Implantable Devices Implantable Cardioverter Defibrillator (ICD) Pacemaker Cardiac Resynchronization Therapy (CRT) Pacemaker Radiation Oncology Management for Radiation Therapy Excluded from : Procedures Performed in the Following Settings: Hospital Inpatient Observation Emergency Room Surgery Center 6

7 List of CPT Procedure Codes Requiring Prior Authorization Review Claims/Utilization Review Matrix to determine CPT codes managed by Magellan Healthcare CPT Codes and their Allowable Billable Groupings Located on RadMD Defer to Health Plan Policies for Procedures not on Claims/Utilization Review Matrix 7

8 Responsibility for Authorization Ordering Provider Responsible for obtaining prior authorization Rendering Provider Ensuring that prior authorization has been obtained prior to providing service Recommendation to Rendering Providers: Do not schedule test until authorization is received 8

9 Prior Authorization Process Overview 9

10 Clinical Decision Making and Algorithms Guidelines are reviewed and mutually approved by {Health Plan} and Magellan Healthcare s Chief Medical Officers Magellan Healthcare s algorithms and medical necessity reviews collect key clinical information to ensure that Horizon NJ Health members are receiving appropriate care prior to more invasive procedures being performed. Our goal ensure that Horizon NJ Health members are receiving the appropriate level of care. Clinical Guidelines available on 10

11 Patient and Clinical Information Required for Authorization GENERAL Includes things like ordering physician information, Member information, rendering provider information, requested examination, etc. CLINICAL INFORMATION Includes clinical information that will justify examination, symptoms and their duration, physical exam findings Preliminary procedures already completed (e.g., x-rays, CTs, lab work, ultrasound reports, scoped procedures, referrals to specialist, specialist evaluation) Reason the study is being requested (e.g., further evaluation, rule out a disorder) Refer to the Prior Authorization Checklists on RadMD for more specific information. 11

12 Automated Timeliness Routing Clinical Specialty Team Review Clinical Specialization Pods Overseen by a Physician Advisor Neurology Abdomen/Pelvis (includes OB-US) General Studies Radiation Oncology Cardiac Orthopedic Oncology Physician Review Team Physician Panel of Board-Certified Physician Specialists with ability to meet any State licensure requirements Specialty Physician panels for peer reviews on specialty products (cardiac, OB Ultrasound, radiation oncology, interventional pain management, surgery, sleep management) 12

13 Document Review Magellan Healthcare may request patient s medical records/additional clinical information When requested, validation of clinical criteria within the patient s medical records is required before an approval can be made Ensures that clinical criteria that supports the requested test are clearly documented in medical records Helps ensure that patients receive the most appropriate, effective care 13

14 Magellan Healthcare to Ordering Provider: Request for Additional Clinical Information A fax is sent to the provider detailing what clinical information that is needed, along with a Fax Coversheet We stress the need to provide the clinical information as quickly as possible so we can make a determination Determination timeframe begins after receipt of clinical information Failure to receive requested clinical information may result in non certification 14

15 Submitting Additional Clinical Information/Medical Records to Magellan Healthcare Two ways to submit clinical information to Magellan Healthcare Via Fax Via RadMD Upload Use the Fax Coversheet (when faxing clinical information to Magellan Healthcare) Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call Be sure to use the Magellan Healthcare Fax Coversheet for all transmissions of clinical information! 15

16 Prior Authorization Process Intake level Initial Clinical Review Physician Clinical Review Requests are evaluated using our clinical algorithm Requests may: 1. Approve 2.Require additional clinical review 3.Pend for clinical validation of medical records Nurses will review request and may: 1. Approve 2.Send to Magellan Healthcare physician for additional clinical review Physicians may: 1. Approve 2.Deny A peer to peer discussion is always available! 16

17 Notification of Determination Approval Notification Denial Notification Authorization Validity Period 60 days from date of request for all Magellan Healthcare products excluding Radiation Oncology Management. 180 days from date of request for Radiation Oncology. Appeal Instructions In the event of a denial, providers are asked to follow the appeal instructions provided in their denial letter. 17

18 Magellan Healthcare s Urgent Authorization Process Urgent Authorization Process If an urgent clinical situation exists outside of a hospital emergency room, please contact Magellan Healthcare immediately with the appropriate clinical information for an expedited review

19 Components Provider Network Provider Assessment Member Scheduling Concierge Claims and Appeals Radiation Safety 19

20 Provider Network Provider Assessment Member Scheduling Concierge Claims and Appeals Radiation Safety Using Horizon NJ Health Network Advanced Imaging Provider Network: Magellan Healthcare will use Horizon NJ Health s network of Freestanding Imaging Facilities (FSFs), Hospitals and In-Office Providers as it s in-network providers for delivering a suite of Medical Specialty Solutions services to Horizon NJ Health members throughout New Jersey. 20

21 Provider Network Provider Assessment Member Scheduling Concierge Claims and Appeals Radiation Safety Provider Assessment A process used by Magellan Healthcare to assess the diagnostic imaging capabilities of the providers within the network. It includes an assessment of the appropriateness of the contracted services rendered at each practice location (called privileging). Privileging components include: Accreditation Equipment Standards Physician and Technologist Education, Training, and Certification Facility Management 21

22 Provider Network Provider Assessment Member Scheduling Concierge Claims and Appeals Radiation Safety Privileging Specifics Horizon NJ Health Overview Modalities privileged by Magellan Healthcare include MR, CT, PET, Nuclear Medicine, Nuclear Cardiology/Nuclear Stress/MPI, Echocardiography, Stress Echocardiography, Cardiac Catheterization, Plain Films, Fluoroscopy Procedures, Mammography, Bone Densitometry and Ultrasound procedures. Providers privileged include freestanding and in-office providers who perform any diagnostic imaging services (we do not privilege hospitals or providers billing for interpretation). Providers who complete an application and comply with Privileging Guidelines are selectable for priorauthorization. All providers performing diagnostic imaging must be approved by Magellan Healthcare s provider assessment process or claims for these services will not be paid. Application Submission Process Application available on RadMD Each practice location must complete a separate application Information gathered is shared with Horizon NJ Health Horizon NJ Health makes the final decision Results are communicated to the provider by Magellan Healthcare NOTE: Providers may be privileged for some modalities, but not privileged for other modalities 22

23 Provider Network Provider Assessment Member Scheduling Concierge Claims and Appeals Radiation Safety Member Facility Scheduling Concierge Goals Provide greater support to the member by coordinating the facility selection, scheduling and transportation of approved advanced imaging services directly with the member Ensures that the facility selected meets the members needs which can result in reduced no-show rates Includes language support as needed. Convenience items include hours of operation, access to public transportation, free parking availability. Facilities offered for scheduling are considered high quality, lower cost facilities but the member can choose any facility Member is offered scheduling/transportation coordination for any in-network facility Reduce administrative burden for physicians on scheduling Medicaid patients by providing concierge services Physician has option of selecting facility if an approved clinical reason exists. 23

24 Provider Network Provider Assessment Member Scheduling Concierge Claims and Appeals Radiation Safety Member Facility Scheduling Concierge How the Works Provider s office requests an advanced imaging test through Magellan Healthcare provider portal ( or Call Center Scheduling program applies to MR, CT and PET (if alternatives are available) During the intake process, the provider will be given the opportunity to notify Magellan Healthcare if a clinical reason exists for bypassing the Member Concierge Scheduling Valid clinical reasons will be approved for the bypass of the program For all other requests, Magellan Healthcare will work directly with the member to select and schedule the facility for the approved test Provider should provide to member an imaging order form Transportation coordination included based on member s needs If Magellan Healthcare does not reach the member, a letter will be sent to the member with an assigned facility and information on how to contact Magellan Healthcare for support 24

25 Provider Network Provider Assessment Member Scheduling Concierge Claims and Appeals Radiation Safety Clinical Exceptions Definition Clinical Exemption Description Definition of child Children age 12 or under. MRS Exclude at this time since the volume is fairly low. Breast MRI Exclude since these are often done as a follow-up to a mammography. Follow-up Procedure Follow-ups within 8 weeks from initial CT or MR scan. Allergic to contrast Patients allergic to contrast material. PET if no alternatives PET technology deployment slower in some rural areas (single source). Impending Surgery Surgery is scheduled or being scheduled at the facility requested. Continuity of Care Primarily for cancer follow-ups that are outside the 8 weeks. Complicating Clinical Factors Patient s clinical issues require a certain facility or patient requires special transportation services provided only by certain facilities Administrative Exceptions Retro requests Excluded Patient is in the facility Excluded 25

26 Provider Network Provider Assessment Member Scheduling Concierge Claims and Appeals Radiation Safety Claims and Appeals How Claims Should be Submitted Rendering providers/imaging providers should continue to send their claims directly to Horizon NJ Health. Providers are strongly encouraged to use EDI claims submission. Check on claims status by logging on to the Horizon NJ Healthwebsite at or Claims Appeals Process In the event of a prior authorization or claims payment denial, providers may appeal the decision through Horizon NJ Health. Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification. NOTE: Consistent with CMS guidelines, multiple procedure discounts are applied when appropriate. 26

27 Provider Network Provider Assessmen t Member Scheduling Concierge Claims and Appeals Radiation Safety Radiation Safety and Awareness Studies suggest a significant increase in cancer in dose estimates in excess of 50 msv U.S. population exposed to nearly six times more radiation from medical devices than in 1980 CT scans and nuclear studies are the largest contributors to increased medical radiation exposure Magellan Healthcare has developed Radiation Awareness Tools and Safety s designed to create patient and physician awareness of radiation concerns 27

28 Provider Network Provider Assessme nt Member Scheduling Concierge Claims and Appeals Radiation Safety Magellan Healthcare s Radiation Awareness Radiation Awareness Identification of High Exposure Members Point of Service Provider Notification and Opportunities for Provider Education Promote Member Awareness and Education Radiation Calculator Over 8,000 visits to the website from 89 countries Apple, Android and Facebook App available Average rating: 4 out of 5 stars 28

29 Provider Tools Toll free authorization and information number Available Monday through Friday, 8 a.m. to 8 p.m. EST o Interactive Voice Response (IVR) System for authorization tracking RadMD Website Available 24/7 (except during maintenance) o o o Request authorization (ordering providers only) and view authorization status Upload additional clinical information View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents 29

30 Ordering Provider: Getting Started on RadMD.com Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations. STEPS: 1. Click the New User button on the right side of the home page. 2. Select Physician s office that orders radiology exams 3. Fill out the application and click the Submit button. You must include your address in order for our Webmaster to respond to you with your Magellan Healthcare-approved user name and password. NOTE: On subsequent visits to the site, click the Sign In button to proceed

31 Rendering Provider: Getting Started on RadMD.com IMPORTANT 1 Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations. Designate an Administrator for the facility who manages the access for the entire facility. STEPS: 1. Click the New User button on the right side of the home page. 2. Select Imaging Facility or Hospital that performs radiology exams 3. Fill out the application and click the Submit button. You must include your address in order for our Webmaster to respond to you with your Magellan Healthcare-approved user name and password. NOTE: On subsequent visits to the site, click the Sign In button to proceed

32 Dedicated Provider Relations Contact Information Magellan Healthcare Dedicated Provider Relations Manager : Charmaine S. Everett Phone: ext cseverett@magellanhealth.com Provides educational tools to ordering Physicians and rendering providers on imaging processes and procedures. Liaison between Horizon NJ Health Provider Relations and Magellan Healthcare. 32

33 RadMD Demo 33

34 Confidentiality Statement for Providers The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to (Health Plan) members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of (Health Plan) and Magellan Health, Inc. 34

35 Thanks