Amerigroup Kansas Provider Training Program

Transcription

1 Amerigroup Kansas Provider Training Program

2 Agenda About NIA The Provider Partnership The Program Components How the Program Works: The Precertification Process The Precertification Appeals Process The Claims Process The Claims Appeals Process Provider Self-service Tools RadMD.com Demo NIA Provider Relations and Contact Information Questions and Answers NIA A Magellan Health Company 2

3 National Imaging Associates

4 About NIA National Imaging Associates (NIA) chosen as the solution for national and regional health plans covering more than 17 million lives due to: o Distinctive clinical focus o Accreditation by the National Committee for Quality Assurance and certification from the Utilization Review Accreditation Commission o Innovation and stability from parent company, Magellan Health Services, which: Enhances operational competencies, IT capabilities and patient support tools Affords financial stability for growth and continued investment in innovative technology Focus/results: Maximizing diagnostic services value and promoting patient safety through: o A clinically driven process that safeguards appropriate diagnostic treatment for Amerigroup Kansas members NIA A Magellan Health Company 4

5 The NIA Partnership Model Dedication to Provider Service and Convenience o o o o o Dedicated Provider Relations staff Precertification call center Interactive Voice Response (IVR) application Education and training programs Ongoing outreach to providers NIA A Magellan Health Company 5

6 Outpatient Imaging Program Components Precertification/ Utilization Management NIA's proprietary, evidence-based decision support algorithms support scripting for call center representatives and online requests, leading to quick procedure approvals or consultations with our radiology experts. Information and Transaction Tools Our website, RadMD.com, enables ordering providers to request and obtain precertification, reference lists of nearby imaging facilities, locate precertifications given and gain rapid precertifications. Providers report a high level of satisfaction with their use of RadMD.com, finding it a simple tool to use and time saving for staff. NIA A Magellan Health Company 6

7 The Precertification Process

8 NIA Precertification is Required for: Any nonemergent outpatient: o CT / CTA o MRI / MRA o PET Scan o CCTA o Nuclear cardiology Any code specifically cited in the Amerigroup Kansas/NIA billable CPT codes claims resolution matrix available at All other procedures are precertified and paid by Amerigroup Kansas per their payment policy. NIA A Magellan Health Company 8

9 NIA Prior Authorization is Not Required for: Emergency room, urgent care centers, inpatient and observation: o CT / CTA o MRI / MRA o PET Scans o CCTA o Nuclear cardiology NIA A Magellan Health Company 9

10 NIA Clinical Expertise and Provider Engagement NIA reviews more than 300,000 advanced imaging provider requests each month. Algorithms and guidelines are reviewed and mutually approved by the Amerigroup Kansas and NIA chief medical officers. Many NIA algorithms recommend substituting more costly but more effective imaging technology. Our goal the most appropriate test early in an episode of care for Amerigroup Kansas members. Clinical consultation is a hallmark of NIA we have 96 board-certified physicians representing radiology and a host of other specialties available for physician-to-physician discussions. NIA A Magellan Health Company 10

11 NIA Clinical UM Precertification Process Physicians office contacts NIA for precertification of study System evaluates request based on physicianentered information Nurse/Clinical Specialty Team Review Physician Review Clinical information complete procedure approved Additional clinical information complete procedure approved Physician approves case without peer-to-peer discussion Clinical information not complete additional information needed? Additional clinical not complete or inconclusive Physician approves case with peer-to-peer discussion? Request for specific clinical information needed W Ordering physician withdraws case Physician denies case 92 percent of all cases receive final determinations within 24 to 48 hours. NIA A Magellan Health Company 11

12 NIA Precertification Process The ordering physician is responsible for obtaining precertification. The rendering provider must ensure precertification is obtained, and it is recommended that you not schedule procedures without precertification. Procedures performed without proper precertification will not be reimbursed. If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed, immediately call NIA at with the appropriate clinical information for an expedited review. If an emergency clinical situation exists outside of a hospital emergency room, immediately call NIA at with the appropriate clinical information for an expedited review. Separate precertification numbers are not needed for CT-guided biopsy, CT-guided radiation therapy and some MR-guided procedures. NIA A Magellan Health Company 12

13 NIA OCR Fax Cover Sheet Submission of Clinical Information NIA does not accept faxes for initial precertification requests. NIA uses OCR technology that allows us to automatically attach the clinical information providers send to an existing precertification request. For the automatic attachment to occur, providers must use the NIA fax cover sheet as the first page of the fax. Obtain an NIA fax cover sheet by: o o o Submitting an online precertification request and printing the cover sheet provided at the end of the submission click Request a Fax Cover Sheet to print for a specific patient Calling the NIA Clinical Support department at to request that a cover sheet be faxed Using the NIA fax cover sheet that accompanies a fax from NIA requesting additional clinical information Following this process will ensure a timely and efficient case review. NIA A Magellan Health Company 13

14 Requests Pended for Clinical Review: Upload clinical documentation or use fax cover sheet NIA A Magellan Health Company 14

15 The Precertification Appeals Process

16 The Precertification Appeals Process Appeals are processed by Amerigroup Kansas The ordering provider and member will receive verbal and written notifications. Central Appeals Processing Amerigroup Kansas P.O. Box Virginia Beach, VA NIA A Magellan Health Company 16

17 The Claims Process

18 How to Submit Claims Rendering and imaging providers continue to send their claims electronically and directly to Amerigroup Kansas. You must submit claims within 90 calendar days from the date of service. You can submit electronic claims by Electronic Data Interchange (EDI) through: o Emdeon (formerly WebMD) Payer ID o Capario (formerly MedAvant) Payer ID o Availity (formerly THIN) Payer ID An EDI claims submission guide is located at providers.amerigroup.com/ks. KanCare Front-end Billing : For your convenience, you can continue sending your Kansas Medicaid claims to the state in the same way you do today. KDHE will submit your claim information to each MCO through daily 837 batch files. If unable to bill electronically, paper claims for Amerigroup Kansas members should be submitted to: The Kansas Dept. of Health and Environment P.O. Box 3571 Topeka, KS NIA A Magellan Health Company 18

19 The Claims Appeals Process

20 The Claims Appeals Process In the event of a precertification or claims payment denial, you may appeal the decision through Amerigroup Kansas. o Follow the instructions on your nonprecertification letter or explanation of payment. NIA A Magellan Health Company 20

21 Self-service Tools

22 NIA Provider Tools Make it Easy to Work with Us Clinical algorithms apply sophisticated criteria to automatically approve most requests and send others for additional review. Phone Telephonic requests to NIA s call center 7:00 a.m. to 7:00 p.m. Central time. Customer Service Representatives are guided through the scripted process by our clinical system. The clinical system evaluates information collected and determines the next steps. Functionality greatly reduces human error and allows expedient contact with the provider. Web RadMD.com is a convenient way to submit precertification requests to NIA it s easy. Proprietary clinical algorithms respond online, prompting the user to answer a few simple questions about the request. Immediate approval or notification of the need for further review is given. NIA s Clinical Guidelines - essential information on clinical criteria are easily available for download or future reference. IVR Magellan s state-of-the-art IVR application allows providers to check on the status of a precertification 24 hours a day, 7 days a week, 365 day a year. Fax Inbound and outbound faxed document images are integrated into the clinical system where they are linked to precertification records. NIA A Magellan Health Company 22

23 Self-Service Tools and Usage IVR application o Use tracking numbers to check the status of cases Website: o Use tracking numbers to review exam requests NIA A Magellan Health Company 23

24 NIA Website: Information on approved precertifications can be viewed at after logging in with your user name and password Search based on the patient s ID number, name or precertification number NIA A Magellan Health Company 24

25 NIA Website: Imaging Facilities User-friendly, near real-time online tool o Log on to Website offers access to: o Member precertifications Date initiated Exam requested Valid billing codes (CPT) o Helpful resources, including Clinical Guidelines for Radiology Procedures NIA A Magellan Health Company 25

26 To get started, visit Click the New User button on the right side of the home page. Fill out the application and click the Submit button. You must include your address so our Webmaster can respond with your NIAapproved user name and password. Everyone in your organization is required to have his or her own separate user name and password due to HIPAA regulations. On subsequent visits to the site, click the Login button to proceed. NIA A Magellan Health Company 26

27 NIA Contact Information NIA Provider Relations Manager Anthony Salvati Phone: Provides educational tools to ordering and rendering providers on imaging processes and procedures. Liaison between Amerigroup Kansas Provider Relations and NIA. NIA A Magellan Health Company 27

28 RadMD.com Demonstration

29 Questions and Answers