Diagnostic Imaging Management

Transcription

1 Diagnostic Imaging Management Provider Office Staff Training Updated May 2012 An independent licensee of the Blue Cross and Blue Shield Association. U7430b, 2/11

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4 Diagnostic Imaging Management Program BCBSNC requires prior review for outpatient high-tech diagnostic services performed February 15, 2007 and after. Program does not include: Low-tech diagnostic services such as X-rays and mammograms Emergency room services, observational stay, hospital inpatient stay BCBSNC has contracted with American Imaging Management (AIM) to implement the diagnostic imaging program for high-tech outpatient imaging services.

5 Program Purpose! " # $ # %& ' & ' (!! '!!!!!!

6 Services and Locations Included Services Outpatient Diagnostic Imaging Services CT, CTA Nuclear Cardiology (e.g. SPECT scans) PET scans Magnetic Resonance Imaging -- MRI/MRA/MRS Locations Included Places of Service Freestanding imaging centers Hospital outpatient In-office use of physician-owned equipment Not-Included Places of Service Inpatient Emergency room Hospital observation Ambulatory surgical center Urgent care center Echocardiography (January 2012) (resting & stress)

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9 Outreach to Providers Providers were sent formal notice on June 1, 2010 informing them of the inclusion of Medicare Advantage members in the DIM Program.

10 Program Guidelines Ordering providers (PCPs or specialists) must obtain an authorization before the service is rendered. PCP does not have to order for a specialist. The ordering provider is the provider requesting the exam. Servicing providers (radiologists) cannot obtain prior review for exams, but should verify authorization prior to scheduling the exam. Authorization is valid for 30 days from the date of the decision.

11 Program Guidelines, continued Retrospective requests will not be considered except for urgent cases filed within two business days after the date of service. Definition of urgent (as defined by ERISA): Occurs suddenly and unexpectedly and requires prompt diagnosis or treatment such that in the absence of immediate care the member could reasonably be expected to suffer chronic illness, prolonged impairment, or the need for more hazardous treatment. BCBSNC provider networks will remain the same (AIM does not have its own provider network). In-network providers are responsible for obtaining prior review on behalf of the member. Member waivers should not be used to avoid the requirement of having to request prior review.

12 BCBSNC Medical Policies BCBSNC has adopted all of AIM s clinical guidelines Guidelines available at: BCBSNC experimental/investigational policies still apply

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30 REQUESTING AUTHORIZATIONS THROUGH AIM

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32 36! Exam Ordering Provider Office Phone Order Entry: Call Center/ Imasis SM OR Web Order Entry: ProviderPortal SM AIM RN Review AIM MD Review Denied (1%-2%) Exam Redirected (3%-6%) Exam Authorization Issued (70%-80%) Authorization Issued (15%-20%) Authorization Issued (10%-15%) Withdrawn (3%-6%)

33 Required Information How does the process work? A six-step, efficient, three to four minute process User registrations and affiliations Information necessary to complete the order at the initial interaction Order Entry Information Required: Member identification number, name, and date of birth Ordering physician information Imaging exams being requested (including body part, right, left, of bilateral) Patient diagnosis (suspected or confirmed) Clinical symptoms/ indications (including intensity/ duration) Results of past treatment history (including previous tests, duration of previous therapy, relevant clinical medical history)

34 Easy to Use: Web Authorizations Submit and receive prior authorizations over the Web on a real-time basis eliminating the need to call AIM Web Features Secure and HIPAA compliant 24/7/365 availability Obtain authorizations Verify approvals Confirm eligibility Provider search Exam Summary that includes exam type, location, and member information CPT Groupers and Clinical Guidelines The ProviderPortal SM can only be accessed through Blue e

35 AIM S PROVIDER PORTAL SM DEMONSTRATION

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49 Case Status If the case is approved when the user initiates the request, the user will receive the authorization number on the screen. If the case requires additional review, the user will receive a notice that your case requires additional review. 5 If further review is needed for any reason, a fax or an outbound call by the nurse will made to obtain additional information. 5 If information provided meets criteria a preauthorization# will be issued at the time of the discussion. 5 An notification will be sent when the case is complete if you have elected this notification process.

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52 VERIFYING AUTHORIZATIONS THROUGH AIM

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57 . Smith, Jane Member # YPPW Sussex Street Wilmington, NC Date of Birth: 01/01/01

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59 SUMMARY

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62 QUESTIONS?