Sleep Solution for Magellan Complete Care of Virginia Members. Provider Training Program for Sleep Management Presented By:
|
|
- Agatha Welch
- 5 years ago
- Views:
Transcription
1 Sleep Solution for Magellan Complete Care of Virginia Members Provider Training Program for Sleep Management Presented By:
2 Magellan Healthcare 1 Program Agenda Sleep Disorders Our Program 1. Magellan Healthcare s Sleep Solution 2. Prior-Authorization Program 3. Clinical Information Request and Review 4. Prior-Authorization Process 5. Notification of Determination 6. Network Approach 7. Provider Tools and Contact Information Questions and Answers 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. 2
3 Sleep Disorders Sleep Disorders can exacerbate medical issues resulting in increased healthcare utilization when left untreated Untreated sleep disorders can contribute to worsening of medical conditions such as heart disease, high blood pressure, diabetes, etc. The impact of sleep disorders is gaining wider recognition Obstructive Sleep Apnea (OSA) affects million people in the United States and is the most prevalent sleep disorder Other disorders include narcolepsy, periodic movement disorder, restless leg syndrome, parasomnia, etc. Magellan Healthcare s Sleep Solution Addresses growing demand for sleep-related services. 3
4 Magellan Healthcare s Sleep Solution for Magellan Complete Care of Virginia Manages utilization of sleep tests Ensures appropriate use of polysomnography based on clinical guidelines Reduces unnecessary repeat studies Encourages sleep assessments when needed due to the potential for other medical co-morbidities Promotes appropriate assessment setting Supports facility-based testing when appropriate 4
5 Magellan Healthcare s Prior Authorization Program August 1, 2017 Only non-emergent procedures performed in an outpatient setting (with the exception of Inpatient Musculoskeletal (MSK) Surgeries) require prior authorization with Magellan Healthcare Procedures Requiring Prior Authorization Excluded from Program: Procedures Performed in the Following Settings: Diagnostic Imaging MR, CT/CTA, PET, CCTA, Nuclear Cardiology/MPI, Stress Echo, Echocardiography Cardiac Interventions Catheterizations and Implantable Devices Musculoskeletal (MSK) Procedures Interventional Pain Management- Spinal Epidural Injections Facet Joint Injections Facet Joint Denervation/Neurolysis MSK Surgery (Inpatient and Outpatient) Lumbar Microdiscectomy Lumbar Decompression Lumbar Spine Fusion (Arthrodesis) Cervical Anterior Decompression with Fusion Single & Multiple Levels Cervical Posterior Decompression with Fusion Single & Multiple Levels Cervical Posterior Decompression (without fusion) Cervical Artificial Disc Replacement Cervical Anterior Decompression (without fusion) Radiation Oncology Management All Radiation Therapy for All Cancer All Other Conditions using Intensity Modulated Radiation Therapy Stereotactic Radiation Therapy and Proton Beam Sleep Studies Hospital Inpatient (excluding MSK Surgery) Observation Emergency Room/Urgent Care Facility 5
6 Sleep Management for Magellan Complete Care of Virginia Magellan Healthcare s sleep solution for MCC VA manages attended sleep assessments and treatment initiation/management services using prior authorization and clinical reviews The MCC-VA program does NOT manage home sleep tests (because this is not a covered benefit) or sleep treatment devices (e.g. CPAP machines) Authorized CPT Code Description Allowable Billed Groupings Sleep disorder treatment initiation and management Sleep study, attended 95782, 95783, 95805, 95807, 95808, 95810,
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 Magellan Complete Care of Virginia s Policies for Procedures not on Claims/Utilization Review Matrix INSERT HEALTH PLAN SPECIFIC MATRIX SCREEN SHOT 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 Algorithm Algorithm Submit Requests by Phone Ordering Physician Telephone Magellan Or Healthcare Online Through Magellan s RadMD Call Center Information Online Through evaluated via algorithm RadMD and medical records Claim Rendering Provider Performs Service Service Authorized 89
10 NIA s Clinical Foundation & Review Clinical Guidelines Are the Foundation Clinical guidelines were developed by practicing specialty physicians, literature reviews, and evidence base. Guidelines are reviewed and mutually approved by Magellan Complete Care and Magellan Healthcare Chief Medical Officers and clinical experts Clinical Algorithms collect pertinent information Algorithms are a branching structure that change depending upon the answer to each question Fax/Upload Clinical Information (upon request) When requested, the patient s medical record will be required for validation of clinical criteria before an approval can be made Clinical Review by NIA s Specialty Clinicians NIA reviews key clinical information to ensure Magellan Complete Care of Virginia members are receiving appropriate care based on their clinical condition Peer-to-Peer Discussion Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines. Our goal ensure that Magellan Complete Care members are receiving appropriate care 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 Clinical information needs to explain the need for an attended sleep test, including: Patient symptoms, relevant patient characteristics, patient s current status and physical exam findings. Screening test results or reports from other diagnostic tests; if request is due to a failed Home Sleep Test, include documentation of results and issues. Contraindications to a Home Sleep Test, including the patient s relevant medical history. Refer to the Prior Authorization Checklists on RadMD for more specific information. 11
12 Requesting Clinical Information NIA may request patient s medical records/additional clinical information Providers may either submit medical records or contact our Nurse Reviewer with additional clinical information Medical records are preferred and are easy to upload via RadMD Helps ensure that patients receive the most appropriate, effective care 12
13 Magellan Healthcare to Ordering Provider: Request for Additional Clinical Information A fax is sent to the provider requesting medical records, 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 13
14 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! 14
15 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 s physician for additional clinical review* Physicians may: 1. Approve 2.Deny A peer to peer discussion is always available! 15
16 Notification of Determination Approval Notification Denial Notification Authorization Validity Period RBM, IPM, MSK Surgery, Cardiac and Sleep - 90 days from the date of the request Radiation Oncology = 180 days from the date of the request Appeal Instructions In the event of a denial, providers are asked to follow the appeal instructions provided in their denial letter 16
17 Magellan Healthcare s Re-review and Urgent/Expedited Authorization Process Re-review Process Re-Reviews will be allowed within 5 business days of initial denial determination 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
18 Using Magellan Complete Care of Virginia s Network Provider Network: Magellan Complete Care of Virginia will use their network of sleep assessment Providers/Facilities for delivering Sleep Management services to Magellan Complete Care of Virginia s membership 18
19 Claims How Claims Should be Submitted Rendering providers/imaging providers should send their claims directly to Magellan Complete Care of Virginia. Providers are strongly encouraged to use EDI claims submission. Check on claims status by logging on to the Magellan Complete Care website at: Claims Appeals Process In the event of a prior authorization or claims payment denial, providers may appeal the decision through Magellan Complete Care of Virginia Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification. 19
20 Provider Tools Provider Tools that Make it Easy for Providers to Partner with Magellan Healthcare Toll free authorization and information number Available Monday Friday 8am 6pm EST Interactive Voice Response (IVR) System RadMD Website Available 24/7 (except during maintenance) Different functionality for ordering and facility/place of service providers Request authorization and view authorization status Upload additional clinical information View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents 20
21 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 username and password. NOTE: On subsequent visits to the site, click the Sign In button to proceed
22 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 username and password. NOTE: On subsequent visits to the site, click the Sign In button to proceed
23 Dedicated Provider Relations Contact Information Magellan Healthcare Dedicated Provider Relations Manager: Name: Charmaine S. Everett Phone: ext or at (410) Providing educational tools to Medical Specialty Ordering Providers and Facilities on processes and procedures. Magellan Complete Care of Virginia provider Service Department Phone:
24 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 Magellan Complete Care of Virginia 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 Magellan Complete Care of Virginia and Magellan Health, Inc. 24
25 Thanks
Magellan 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 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 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 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 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 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 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 informationHMSA s Interventional Pain Management and Spine Surgery Program
HMSA s Interventional Pain Management and Spine Surgery Program Presented by: Laurie Kim, Director, Provider Relations and Account Management Hawai i Magellan Healthcare 1 Training Program 1 National Imaging
More informationWelcome to Arbor Health Plan Provider Training
Welcome to Arbor Health Plan Provider Training To join the teleconference: Select the Call Me option To mute/un mute your phone click the mute button or Press *6 Thank you for not putting your phone on
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 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 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 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 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 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 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 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 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 informationGeneral Who is National Imaging Associates, Inc. (NIA)?
National Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For the Post Service Therapy Review Program For Home State Health Plan Providers Question Answer General Who is National Imaging
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 informationNational Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For NH Healthy Families Providers Post Service Therapy Review Program
National Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQ s) For NH Healthy Families Providers Post Service Therapy Review Program Question Answer GENERAL Who is National Imaging Associates,
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 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 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 informationHMSA QUEST Integration Plan. Par Provider Information Webinar May 24,2017
HMSA QUEST Integration Plan Par Provider Information Webinar May 24,2017 Agenda Excluded Providers Member Cost Share Service Coordination Referrals and Pre-certifications EPSDT QUEST Integration Fee Schedules
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 informationHMSA QUEST Integration Plan. Par Provider Information Webinar May 23,2018
HMSA QUEST Integration Plan Par Provider Information Webinar May 23,2018 Agenda Provider Enrollment/Re-enrollment Excluded Providers Member Cost Share Service Coordination Referrals and Pre-certifications
More informationHALIFAX PHO BOARD OF DIRECTORS MEETING
CLIENT UPDATE 1 FALL 2011 HPHO SPONSORED CODING CLASS 2 MALPRACTICE INSURANCE / CHANGES 3 HIGHLIGHTS: MULTIPLAN & SENTARA 4 HIGHLIGHTS: COVENTRY 5 HIGHLIGHTS: VA PREMIER 6 Provider focus ADDRESSING THE
More informationProvider Frequently Asked Questions (FAQs)
1 Provider Frequently Asked Questions (FAQs) November 2012 BlueAdvantage Administrators of Arkansas will be working with AIM Specialty HealthSM (AIM) on a new Integrated Imaging Program for outpatient
More informationPA/MND Review of Spine Surgery services Questions & Answers
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
More informationIn this issue Page. anthem.com. Important phone numbers. May 2015 SPECIAL EDITION
May 2015 SPECIAL EDITION In this issue Page Announcements May 2015 Network Update addresses transition to AIM Specialty Health ; new incentive opportunity regarding health assessments for members with
More informationRSNA EMPLOYEE BENEFIT TRUST PLAN II S2502 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to age 26 Filing Limit 1 year from date of service Mailing Address & PPO Company. Remit claims to:
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 informationWILLIS KNIGHTON MEDICAL CENTER S2763 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Customized COB Dependents Children birth to 26 Filing Limit 12 months For employees that work in a WKHS location within the primary HealthPlus
More informationHOW TO GET SPECIALTY CARE AND REFERRALS
THE BELOW SECTIONS OF YOUR MEMBER HANDBOOK HAVE BEEN REVISED TO READ AS FOLLOWS HOW TO GET SPECIALTY CARE AND REFERRALS If you need care that your PCP cannot give, he or she will refer you to a specialist
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 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 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 informationBehavioral Health Provider Training: Program Overview & Helpful Information
Behavioral Health Provider Training: Program Overview & Helpful Information Overview The Passport Behavioral Health Program provides members with access to a full continuum of recovery and resiliency focused
More informationProcedures that require authorization by evicore healthcare
Go directly to the Blue Cross code lists. Go directly to the BCN code lists. Overview The codes listed in this document represent the procedures requiring authorization for the following: Select Blue Cross
More informationQuick Reference Card
Amerigroup District of Columbia, Inc. Quick Reference Card Precertification/notification requirements Important contact numbers n Revenue codes https://providers.amerigroup.com/dc DCPEC-0176-17 Important
More informationClinical Appropriateness Guidelines
Clinical Appropriateness Guidelines Guideline Description and Administrative Guidelines Effective Date: September 5, 2017 Proprietary Date of Origin: 03/30/2005 Last revised: 07/26/2016 Last reviewed:
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 informationProvider Portal Hints & Tips Frequently Asked Questions
Provider Portal Hints & Tips Frequently Asked Questions 1 Medical Review-Claim Appeal Hints & Tips Claim Appeals The Dean Health Plan Medical Affairs Department reviews the claim and associated medical
More informationBehavioral Health Provider Training: Program Overview & Helpful Information
Behavioral Health Provider Training: Program Overview & Helpful Information Overview The Passport Behavioral Health Program provides members with access to a full continuum of recovery and resiliency focused
More informationCONRAD INDUSTRIES, INC. S2489 NON GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children to age 26 Filing Limit 12 months from date of service Mailing Address & PPO Company. PPO Co.: PPO CIGNA
More informationAdverse Outcome Reporting Requirements. July 19, 2016
Adverse Outcome Reporting Requirements July 19, 2016 Magellan of Virginia (Magellan) serves as the contracted Behavioral Health Services Administrator for the Department of Medical Assistance Services
More informationChiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverage for SOUTHERN CALIFORNIA IBEW-NECA HEALTH TRUST FUND
EOC #5 - Kaiser Foundation Health Plan, Inc. Southern California Region Chiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverage for SOUTHERN CALIFORNIA IBEW-NECA
More informationParticipating Provider Prior Authorization Guide
This is a list of common services that typically require prior authorization and may not be all-inclusive. For questions, please contact Magellan Complete Care Customer Services at (800) 327-8613. Participating
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 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 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 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 informationHOME BANK - S2395 NON-GRANDFATHERED CONSUMER DRIVEN HEALTH PLAN BENEFIT SHEET
CONSUMER DRIVEN HEALTH PLAN BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 180 days from incurred Filing Limit date, except when 180 days would
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 informationCalifornia Provider Handbook Supplement to the Magellan National Provider Handbook*
Magellan Healthcare, Inc. * California Provider Handbook Supplement to the Magellan National Provider Handbook* *In California, Magellan does business as Human Affairs International of California, Inc.
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 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 informationPsychosocial Rehabilitation (PSR) H2017. Presented by the Clinical and Quality Teams September 2016
Psychosocial Rehabilitation (PSR) H2017 Presented by the Clinical and Quality Teams After today s training you will be able to: Determine Department of Medical Assistance (DMAS) Medical Necessity Criteria
More informationEnterprise Health Solutions (EHS) Processing Platform
1 Enterprise Health Solutions (EHS) Processing Platform West Virginia Family Health Plan (WVFH) transitioned to the EHS claims processing platform on 1/1/18. The system transition will provide you with
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 informationPROVIDER APPEALS PROCEDURE
PROVIDER APPEALS PROCEDURE 1. The Provider or his/her designee may request an appeal in writing within 365 days of the date of service 2. Detailed information and supporting written documentation should
More informationBehavioral Health Provider Training: BHSO updates
Behavioral Health Provider Training: BHSO updates Agenda Diagnosis Code 799 Laboratory Work CPT Code Q3014- Telehealth BHSO Claims submission Process Targeted Case Management Diagnosis Codes Diagnosis
More informationStaggered Roll Out Plans of Care Moving to a Fee for Service Sharon Weber
Staggered Roll Out Plans of Care Moving to a Fee for Service 5-7-18 Sharon Weber Staggered Roll Out To transition to a fee for service rather then a bundled rate the POC s will need to be discharged and
More informationProviderNews2014 Quarter 3
TEXAS ProviderNews2014 Quarter 3 Our Quality Improvement program The Amerigroup* Quality Improvement (QI) program is committed to excellence in the quality of service and care our members receive and the
More informationMedical 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 informationChapter. CPT only copyright 2008 American Medical Association. All rights reserved. 30Radiation Therapy Services
Chapter 30Radiation Therapy Services 30 30.1 Enrollment...................................................... 30-2 30.2 Benefits, Limitations, and Authorization Requirements...................... 30-2
More informationObservation Services Tool for Applying MCG Care Guidelines
In the event of a conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include
More informationNew provider orientation. IAPEC December 2015
New provider orientation IAPEC-0109-15 December 2015 Welcome 2 Agenda Introduction to Amerigroup Provider resources Preservice processes Member benefits and services Claims and billing Provider responsibilities
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 informationChapter. CPT only copyright 2009 American Medical Association. All rights reserved. 31Radiation Therapy Services
Chapter 31Radiation Therapy Services 31 31.1 Enrollment...................................................... 31-2 31.2 Benefits, Limitations, and Authorization Requirements...................... 31-2
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 informationProvider s Frequently Asked Questions Availity in California
Page - 1 - of 6 Provider s Frequently Asked Questions Availity in California Who is Availity? Availity is a multi-payer portal at availity.com that gives physicians, hospitals and other health care professionals
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 informationOhio Non-participating. Quick Reference Guide. UHCCommunityPlan.com. Community Plan. UHC2455a_
Ohio Non-participating Quick Reference Guide UHCCommunityPlan.com UHC2455a_20130610 Important Phone Numbers Administrative Office 412-858-4000 Provider Services Department 800-600-9007 Fax: 877-877-7697
More informationUTILIZATION MANAGEMENT Section 4. Overview The Plan s Utilization Management (UM)
Overview The Plan s Utilization Management (UM) Program is designed to meet contractual requirements and comply with federal regulations while providing members access to high quality, cost effective medically
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 informationNEVADA HEALTH CO-OP SOUTHERN STAR/ESTRELLA GOLD 100% 34996NV
NEVADA HEALTH CO-OP SOUTHERN STAR/ESTRELLA GOLD 100% 34996NV003 0002 Attachment A Benefit Schedule Lifetime Maximum: Unlimited. Benefits apply when you obtain or arrange for Covered through a Nevada Health
More informationEmpire BlueCross BlueShield Professional Commercial Reimbursement Policy
Subject: Place of Service NY Policy: 0018 Effective: 12/01/2015 02/21/2016 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria
More information2018 Authorization and Notification Requirements Medical Services
2018 Authorization and Notification Requirements Medical Services For the following plans: MSHO=Minnesota Senior Health Options MSC Plus=Minnesota Senior Care Plus Connect=Special Needs BasicCare Connect
More informationMedicare Advantage Referral-Required Plans
Medicare Advantage Referral-Required Plans Overview UnitedHealthcare Medicare Advantage referral-required plans emphasize the role of the primary care physician (PCP). Members choose a PCP who oversees
More informationWORKLINK PROVIDER MANUAL TABLE OF CONTENTS D. PRE-AUTHORIZATION PROVIDER RECONSIDERATION PROCEDURES P.4
WORKLINK PROVIDER MANUAL TABLE OF CONTENTS A. INTRODUCTION LETTER P.2 B. PROVIDER INFORMATION SHEET P.3 C. BILL PROCESSING & CLAIMS FILE INFORMATION P.3 D. PRE-AUTHORIZATION PROVIDER RECONSIDERATION PROCEDURES
More informationBehavioral health provider overview
Behavioral health provider overview KSPEC-1890-18 February 2018 Agenda Provider manual and provider website Behavioral Health (BH) program goals Access and availability standards Care coordination and
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 informationAnthem Blue Cross and Blue Shield in New Hampshire Precertification/Prior Authorization Guidelines
Anthem Blue Cross and Blue Shield in New Hampshire Precertification/Prior Authorization Guidelines The following guidelines apply to Anthem Blue Cross and Blue Shield ( Anthem ) products issued and delivered
More informationIPN s credentialing/recredentialing program has been certified by NCQA as of August 12, 2014.
Credentialing is primary source verification of a health care practitioner s education, training, work experience, license, etc. A variety of resources are used to verify the information provided by the
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 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 informationSummary of Benefits CCPOA (Basic) Custom Access+ HMO
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits CCPOA (Basic) Custom Access+ HMO CCPOA Effective January 1, 2019 HMO Benefit Plan This Summary of Benefits
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 informationReferrals, Prior Authorizations, Medical Management, and Appeals
Referrals, Prior Authorizations, Medical Management, and Appeals 1 An Independent Licensee of the Blue Cross Blue Shield Association 044506 (12-21-2017) 2017 Premera. Proprietary and Confidential. Referrals
More informationProvider Contracting and Re-credentialing. Third Thursday Provider Call (August 20, 2015) Gail Fowler, Network Development Administrator
Provider Contracting and Re-credentialing Third Thursday Provider Call (August 20, 2015) Gail Fowler, Network Development Administrator New Provider Contracting - In the Louisiana Behavioral Health Partnership
More informationNUCLEAR MEDICINE RESIDENT DUTIES
NUCLEAR MEDICINE RESIDENT DUTIES General The American Board of Radiology requires four months training in Nuclear Medicine. Residents will be assigned at least 4 rotations on service. Rotations will be
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 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 informationVA DMAS CMHRS, Residential, EPSDT Behavioral Therapy (ABA), and TFC Case Management Service Request Process
VA DMAS CMHRS, Residential, EPSDT Behavioral Therapy (ABA), and TFC Case Management Service Request Process Presented by: Katie Richardson, Lead IT Analyst Rick Kamins, Ph.D., Chief Clinical Officer, Magellan
More informationWelcome to Kaiser Permanente: NAME (Please Print):
Welcome to Kaiser Permanente: NAME (Please Print): You have made a great choice for your health! We value each and every member and aim to make your transition from your prior insurance company to Kaiser
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 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 informationSummary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000
Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Group Plan PPO Savings Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this
More information