HealthChoice Radiology Management. March 1, 2010

Transcription

1 HealthChoice Radiology Management March 1, 2010

2 Introduction Acting on behalf of our Medicaid customers in Maryland (HealthChoice), UnitedHealthcare has worked with external physician advisory groups to develop a program that promotes more effective use of imaging services and addresses preventable radiation exposure. This change is based on our concern for patients who are subject to preventable radiation exposure, and the need to improve compliance with evidence-based and professional society guidance in the use of these expensive health care assets. 2

3 Introduction Further, it aligns UnitedHealthcare business processes to streamline the administrative experience for physicians, hospitals and facilities. This program will provide a more consistent application of current scientific clinical evidence to diagnostic imaging services. It also provides a consistency in operating imaging pre-service programs with other payers and across other UnitedHealthcare network facing companies. Failure to complete the Radiology Prior Authorization protocol will result in denial for medical necessity. Denied claims may not be balanced-billed to the patient. 3

4 Program Start Effective March 22, 2010 for services rendered on or after April 5, 2010 All providers will be required to have an approved authorization for UnitedHealthcare HealthChoice members prior to performing an outpatient advanced imaging study. 4

5 Modalities Requiring Authorization UnitedHealthcare will require prior authorization for the following modalities, for HealthChoice members: CT/CTA MRI/MRA PET Nuclear Medicine Nuclear Cardiology 5

6 Places of Service Where Authorization is Required Authorizations are required in the following outpatient settings: All Freestanding Imaging Centers Hospital (outpatient only) Physician Office Authorizations not required in these settings: Hospital (inpatient) Emergency Room Observation Unit Urgent Care Center

7 General Process The ordering physician is required to contact UnitedHealthcare by phone, Web or FAX. The physician s office will provide the test being ordered, along with the patient s demographic information, ordering physician s information and the rendering facility. Then the pertinent clinical information will be provided and reviewed by a clinical reviewer. If the case meets evidence-based clinical guidelines, an authorization number will be provided. For requests made on behalf of a Medicaid member, if the case does not meet evidence-based clinical guidelines, the case will not be certified and appeal information will be given to the ordering physician. An opportunity for a Peer-to-Peer request will be given to the provider and should occur within 14 business days of the denial determination.

8 Initiating Authorization The ordering physician/designee is responsible for obtaining the authorization using one of these methods: Online - preferred method Go to Log in with user ID and password (first time users will be asked to register for online services) Phone FAX Call Monday through Friday: 7:00 A.M. to 7:00 P.M. Closed Thanksgiving, Christmas, New Year s Day, Memorial Day, July Fourth, Labor Day Recorded messages may be left after hours Download, print and fill out the appropriate FAX form from the applicable website listed above FAX the completed form to

9 Initiating Authorization All authorization requests will require the following information: User login and password (available online) Physician s information Patient s ID, name and date of birth Requested study and/or CPT code Diagnosis code Clinical information pertaining to requested study, such as: Reason for the test Medications and their durations Findings of recent physical examinations Results of lab blood tests Recent CT, MR or PET results Biopsy results

10 Approved Authorizations Authorization numbers are returned via FAX as soon as the clinical information is reviewed, but no later than 2 business days from receipt of all clinical information. Rendering providers can validate a prior authorization online at When submitted for authorization online, cases meeting evidence-based clinical criteria receive authorization immediately, with the authorization number displaying online at that time. When submitted via phone, cases meeting clinical criteria will be given verbal authorization followed by a FAX notification to the ordering provider within 2 business days. Authorizations are valid for 45 days from the date of approval.

11 Adverse Determination Cases not consistent with evidence-based criteria may not be approved. Should a prior authorization request be denied, UnitedHealthcare will notify the referring provider within 2 business days. For the providers, letters of non-certification will include an explanation and guidelines for appealing. Providers and members may receive written and/or telephonic notification based on the Health Plan specific requirements.

12 Verifying the Status of an Existing Request Providers may check status of all existing requests online at This includes requests submitted via phone or FAX as well. Members are not able to verify status online, only providers may log into the site. Information needed for search: Health Plan Provider ID Patient ID Patient s Date of Birth Or: Case Number or Authorization Number

13 Modifying an Authorization Request In an instance where a CPT code for the authorized procedure differs from the CPT code for the rendered procedure, the ordering or rendering provider will be required to contact AmeriChoice to modify the request. The following modifications to authorized procedures are required: Change in modality Adding contrast for MRI Addition of contiguous body parts The ordering or rendering providers must call and select Customer Service. IMPORTANT: The provider has up to 2 business days from date of service to request a modification.

14 Rendering Provider Responsibility The responsibility of the rendering physician is to ensure authorization is on file prior to performing services. Authorizations can be validated by rendering providers online at

15 Access to Medical Directors The ordering physician may speak with a National Medical Director at any point during the authorization process. Call and select the option to speak with a National Medical Director. Only one of the following may speak to a National Medical Director: Ordering Physician, Ordering Physician s Assistant or Nurse Practitioner

16 Case Numbers A case number is assigned to every request. Case numbers simply identify that an authorization request is being made; these numbers are used for reference purposes only. A case number cannot be used as an authorization number. Case numbers are not valid for claim payment. The format is a 10-digit numeric value. Example:

17 Claims There will be no change to claims administration at UnitedHealthcare; providers are to continue submitting claims as they do today. Questions about claim payment issues should continue to be directed to the UnitedHealthcare Service Center.

18 Additional Resources Additional resources are available online at Select Physicians Select your state Under Tools select Prior Authorizations Login