Precertification Tips & Tools

Transcription

1 Working with Anthem Subject Specific Webinar Series Precertification Tips & Tools Access to Audio Portion of Conference: Dial-In Number: Conference Code: # Please Mute Your Phone Use the mute button or press *6 This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.

2 Agenda Housekeeping & Announcements Precertification Tips & Tools Precertification/Predetermination o Who are the members? o What are the products? o What are the services? o BlueCard Program members 2

3 Agenda continued Precertification Tips & Tools Precertification Tools o Interactive Care Reviewer (ICR) Demonstration o AIM Specialty Health o OrthoNet o Anthem Medicare Advantage (1) and Anthem Medicaid (BadgerCare Plus) Precertification Tools (2) Links to more information Questions and answers (1) Available for Individual Medicare Advantage members. Alpha prefixes VOE, ZRB, VOT (2) Available for Anthem Medicaid members. Alpha prefix ZRA 3

4 Working with Anthem Subject Specific Webinar Series Housekeeping & Announcements Navigation and Handouts Click here for handouts 1. Select items by checking the boxes 2. Select a destination on your computer 3. Press OK to download Control your view Full Screen 4

5 Who are the members? How to identify members with local WI products using tools on Anthem.com Review the member s identification card o Sample Member ID Cards Located under Answers@Anthem choose Local Anthem Member Identification Cards Ready Reference Guide o Lists WI alpha prefixes and applicable Medical Management telephone numbers and fax numbers accessed on the Contact Us page 5

6 What are the products? Blue Products (commercial) Blue Preferred (HMO) Blue Access SM (PPO) Blue Preferred Plus (POS) Blue Priority Blue Traditional Individual - Anthem (Bronze/Silver/ Gold), Anthem (Bronze/Silver/Gold/Catastrophic) Blue Priority X WI (on Exchange) Individual and Small Group - Anthem (Bronze/Silver/ Gold), Anthem(Bronze/Silver/Gold/Catastrophic) Blue Priority WI (off Exchange) (1) (1) 2014 Small Group plan name Anthem (Essential/Core/Preferred) Direct Access until group renewal. 6

7 What are the products? Blue Products (commercial) continued Consumer Directed Health Plans (Lumenos) o Health Incentive Account (HIA), Health Reimbursement Account (HRA) and Health Savings Account (HSA) Local Self-Funded Administrative Services Only (ASO) Anthem Medicaid (BadgerCare Plus) Anthem Medicare Advantage 7

8 What are the services? Precertification Guidelines Inpatient Admission Outpatient Services Radiology, Radiation Therapy, Sleep Management, Specialty Pharmacy Transplants Mental Health & Substance Abuse 8

9 What are the services? Access through Precertification Guidelines link on Provider Home Page Through Medical Policy, Clinical UM Guidelines and Pre-Cert Requirements tout on any page for local and BlueCard out-ofarea members 9

10 What are the services? Local guidelines by product Consistent format Different content 10 10

11 What are the services? Precertification (Tools) Interactive Care Reviewer (ICR) Imaging and Specialty Services o AIM Specialty Health Additional precertification tools o Physical Therapy/Occupational Therapy Utilization Management Program FAQs 11 11

12 What are the services? Medical Policies & Clinical UM Guidelines Reviewed at least annually with changes communicated via Network Update Newsletter or eupdate (fka Rapid Update) in advance Online Google search by term or code 12 12

13 What are the services? BlueCard Program Members Medical Policy and Precertification Guideline Router o Accessed from anthem.com o Choose Medical Policy and Clinical UM Guidelines (for BlueCard Outof-Area members) or o Pre-certification / Pre-authorization Requirements (for BlueCard Outof-Area members) o Enter the member s three-digit alpha prefix Routes to the member s home Plan where you view and search 13 13

14 What are the services? BlueCard Program Members continued Precertification via Availity Authorizations & Referrals to ICR o Enter member s alpha prefix and expected date(s) of service o If prefix is out-of-state (BlueCard) system will prompt user to enter TIN and NPI o User is routed to electronic precert tool at the member s home plan o More information: April 2014 Network Update Newsletter Call the precertification number on the back of the member s identification card Call BLUE (2583) if you don t have the member s identification card o Automatically transferred to the appropriate area at the member s home plan 14 14

15 What are the services? BlueCard Program Members continued Providers responsible for obtaining pre-service review (precertification / preauthorization) for inpatient services effective July 1, Notification of emergency/urgent admissions within 72-hours. Providers notify the member s Home Plan within 48-hours when a change to the original pre-service review occurs. Members held harmless for penalty reductions if inpatient admission is not precertified

16 To access ICR from the Availity Web Portal choose Authorizations under the Auths and Referrals link on the left navigational bar. Availity Web Portal at Now, as part of the Electronic Provider Access (EPA) mandate, providers will need to enter the member alpha prefix and the service dates. Routing will be based on the prefix entered. Users will be prompted to add Tax ID and NPI for an out of area provider

17 Provider Requirements Obtain pre-service review for out-ofarea members, same as local members. Notify member s Plan of change in pre-service approval within 48-hours. Notify member s Plan for emergency /urgent pre-service review within 72 hours. Inpatient* facility services only. Hold out-of-area members harmless. Sanctions are in the contract with local Blue Plan EPA tool available in 2014 Member Benefits Out-of-area and local members are treated the same for precertification requests. Consistent and more seamless care management processes for members. Members not held liable for preservice sanctions if a facility does not obtain precertification. Members remain responsible for medical necessity determinations. *Inpatient facilities include hospitals, skilled nursing and inpatient rehabilitation facilities

18 Precertification Tools Interactive Care Reviewer (ICR) ICR FAQs o Outpatient Medical o Inpatient Medical Imaging and Specialty Services AIM Specialty Health o Imaging & Echocardiography o Outpatient Radiation Therapy o Sleep Management o Specialty Pharmacy Additional precertification tools Physical Therapy/Occupational Therapy Utilization Management Program FAQs 18 18

19 Precertification Tools Interactive Care Reviewer (ICR) Tool Capabilities o Submit Outpatient and Inpatient Medical Precertification o Behavioral Health Precertification o Inquiry on any precertification from your ordering physician or rendering facility o View Determination Letters Not included o Medicare Advantage o Federal Employee Program (FEP) o Some Anthem National Accounts o Services managed by AIM Specialty Health 19 19

20 Precertification Tools Interactive Care Reviewer (ICR) Use Advantages Determine if a precert is needed Inquiry capability Easy to use Reduces the need to fax No additional cost Access almost anywhere Comprehensive view of all precertification requests Register for ICR Training webinar 20 20

21 Precertification Tools Imaging and Specialty Services Tools Imaging and Echocardiography Precertification CPT codes MPI or SE Work Sheet Oncology Drugs and Codes for Anthem Cancer Care Quality Program Quick Reference Guide to AIM Specialty Health Radiation Therapy Precertification CPT codes Sleep Management Precertification CPT codes Specialty Pharmacy Precertification drugs and code 21 21

22 AIM Specialty Health (AIM) Who is AIM? Anthem, Inc. subsidiary Experienced in the management of radiology, cardiology, oncology, sleep medicine and specialty pharmacy benefits. Mission Improve the clinical appropriateness, safety and affordability of healthcare services

23 AIM Specialty Health (AIM) The services Imaging & Echocardiography Outpatient Radiation Therapy Cancer Care Quality Program Sleep Management Specialty Pharmacy The members Local and national Anthem commercial plans Some self-funded plans Anthem Medicaid (BadgerCare Plus Anthem Medicare Advantage Copyright 2013 AIM Specialty Health, All Rights Reserved 23 23

24 AIM Specialty Health (AIM) Who initiates the precertification request? Ordering providers are responsible for initiating requests by providing patient and related clinical information. Servicing providers can verify that a pre-certification has been approved. Servicing and DME providers have the ability to order within the Sleep program. Pre-certification numbers are valid for 30 days from the date the request is approved

25 AIM Specialty Health (AIM) Information needed Insurance information- Member identification number Patient information -Name and date of birth Ordering provider information Name and address Exam type CPT code(s) if available Patient s symptoms/diagnosis Results of relevant previous studies 25 25

26 Clinical Review Process Review Specialist or Provider Portal R.N. Reviewer M.D. Reviewer Web Or Phone 0 Verifies member eligibility, and ordering provider and servicing facility are in the health plan s network Conducts initial clinical review using clinical scripts Case approved or passed to registered nurse R.N. picks up case from portal queue or call transferred to R.N. R.N. reviews case and calls provider office for additional information, if needed R.N. uses clinical guidelines and nursing experience to approve case or forward to medical doctor reviewer M.D. uses clinical experience and clinical guidelines M.D. calls for peer-topeer conversation Renders outcome: Approved Denied Withdrawn Redirected Precertification is effective for 30 days from the date the case is closed Authorized Authorized Outcome 70-80% of cases meet criteria and are completed in under 4 minutes 20-30% of cases meet criteria without additional information 10-15% of cases require peer-to-peer discussion of clinical rationale 26 26

27 AIM Specialty Health (AIM) Decision notification Authorization or denial letters sent to the Anthem member, the ordering and servicing provider. o Authorization numbers* given at the time of approval via the online tool or the AIM Representative. Included in letters. o Denial letters hold information on appeal rights *The initial authorization number and the number on the authorization letter will be different. This will not be an issue for claims payment 27 27

28 AIM Specialty Health (AIM) Access through Availity User access is granted by the provider organizations Primary Access Administrator (PAA). Your User ID / password for Availity is separate from and may be different than your User ID/and password on MyAnthem. Work with your organization s PAA if you do not yet have an Availity User ID

29 AIM Specialty Health (AIM) Anthem Services Registration on Availity 1. Log in to Availity and click My Account Anthem Services Registration. If prompted, select your organization next. 2. In the Display field, click Non-Registered Users. 3. Enter the users MyAnthem User ID, also known as the EAM ID, in the field provided. a) To enable the Register button, enter one or more user Anthem Blue Cross and Blue Shield MyAnthem User IDs b) If the user does not have a MyAnthem User ID, register the user on MyAnthem, and then return to this page to register the user. 4. Click Register. 5. Note that the User(s) Registered page displays. a) If registration is successful, the user(s) can begin using the services immediately. b) If an error message displays, the registration or change was not successful for that user. Review the message and verify the information you entered. Make note of the Transaction ID if you need to contact Availity Client Services for assistance. Please note that the user s first name, last name, and Anthem EAM ID in Availity must match exactly with how the user is registered with Anthem. Availity is an independent company providing a wide variety of online tools that allow providers to access real-time information from multiple payers via one secure sign-on 29 29

30 AIM Specialty Health (AIM) MyAnthem Manage My Users Site Administrators are able to update any alterable field in their own records, and are responsible for the records of any users attached to them. ***** For certain Anthem-specific services, user access must be maintained on both MyAnthem and Availity. ***** We strongly recommend the same individuals manage access on both secure portals

31 AIM Specialty Health (AIM) Under Auths and Referrals Once you click I Agree, the system will open a new tab and log you seamlessly into the AIM Specialty Health precert site. Tip: Be sure you have allowed Pop-Ups within your Internet browser. Many functionalities within Availity operate by opening a separate screen

32 AIM Specialty Health (AIM) Log on The HIPAA disclaimer must be accepted before you will be allowed further into the secure AIM Portal functionality. Copyright 2013 AIM Specialty Health, All Rights Reserved 32 32

33 AIM Specialty Health (AIM) Search by Member Name and Date of Birth The AIM Specialty Health functionality now offers you the ability to search for a member by Name & Date of Birth Helpful when the member ID is incorrect or not available. The search requires a minimum of 2 letters in each field. Copyright 2013 AIM Specialty Health, All Rights Reserved 33 33

34 AIM Specialty Health (AIM) Select the appropriate member Your search results will display a list of members who meet your search criteria. Select the member s name from the list to continue. Once you choose a member, a pop up box will appear asking you to confirm the member s phone number. Copyright 2013 AIM Specialty Health, All Rights Reserved 34 34

35 AIM Specialty Health (AIM) Duplicate case verification Copyright 2013 AIM Specialty Health, All Rights Reserved 35 35

36 AIM Specialty Health (AIM) Select ordering provider A directory of ordering providers will appear. The access your SA grants you determines which physicians appear in your Ordering list. Copyright 2013 AIM Specialty Health, All Rights Reserved 36 36

37 AIM Specialty Health (AIM) Exam type and description As you make each selection, the system will eliminate options that no longer apply. For example, if you enter a CT of the head, when you get to symptomology you likely will not see foot pain as a primary reason for requesting the exam. Copyright 2013 AIM Specialty Health, All Rights Reserved 37 37

38 AIM Specialty Health (AIM) Clinical review Copyright 2013 AIM Specialty Health, All Rights Reserved 38 38

39 AIM Specialty Health (AIM) Clinical review continued Copyright 2013 AIM Specialty Health, All Rights Reserved 39 39

40 AIM Specialty Health (AIM) Clinical review continued Copyright 2013 AIM Specialty Health, All Rights Reserved 40 40

41 AIM Specialty Health (AIM) Clinical summary review Copyright 2013 AIM Specialty Health, All Rights Reserved 41 41

42 AIM Specialty Health (AIM) Choose a facility State Copyright 2013 AIM Specialty Health, All Rights Reserved 42 42

43 AIM Specialty Health (AIM) Review entry and submit Ordering Provider Name Address City, State, Zip Phone: Fax: NPI Servicing Provider Name Address City, State, Zip Phone: Fax: NPI Copyright 2013 AIM Specialty Health, All Rights Reserved 43 43

44 AIM Specialty Health (AIM) Results: Immediate Approval Ordering Provider Name Address City, State, Zip Phone: Fax: NPI Servicing Provider Name Address City, State, Zip Phone: Fax: NPI Copyright 2013 AIM Specialty Health, All Rights Reserved 44 44

45 AIM Specialty Health (AIM) Results: Nurse Review- Additional Clinical Request Copyright 2013 AIM Specialty Health, All Rights Reserved 45 45

46 AIM Specialty Health (AIM) Results: Nurse Review- Request Status Ordering Provider Name Address City, State, Zip Phone: Fax: NPI Servicing Provider Name Address City, State, Zip Phone: Fax: NPI Copyright 2013 AIM Specialty Health, All Rights Reserved 46 46

47 AIM Specialty Health (AIM) View Requests Step by step tutorials available on the Provider Resources box found on the AIM Provider Portal home page. Portal login is required. Copyright 2013 AIM Specialty Health, All Rights Reserved 47 47

48 Physical and Occupational Therapy Utilization Management through OrthoNet Effective November 1, 2015, Anthem implemented a physical therapy and occupational therapy benefit management program for outpatient and office service. The program is administered by OrthoNet LLC. Who is OrthoNet LLC? OrthoNet is a leading musculoskeletal management company located in White Plains, NY. It is a provider-based company with ties to leading practitioners in the Anthem service areas. OrthoNet has significant experience in promoting best practices and evidence-based health care. It works with physical and occupational therapists as well as other providers of therapy services and their patients

49 Physical and Occupational Therapy Utilization Management Members Included Anthem local fully insured individual, small and large group commercial members Blue Preferred (HMO) Blue Access SM (PPO) Blue Preferred Plus (POS) Blue Priority Blue Traditional ACA compliant plan members Individual - Anthem (Bronze/Silver/ Gold), Anthem (Bronze/Silver/Gold/Catastrophic) Blue Priority X WI (on Exchange) Individual and Small Group - Anthem (Bronze/Silver/ Gold), Anthem(Bronze/Silver/Gold/Catastrophic) Blue Priority WI (off Exchange) Administrative Services Only (ASO) groups may add this program upon renewal after

50 Physical and Occupational Therapy Utilization Management Members Excluded Anthem National Accounts Federal Employee Benefit Program (FEP) Medicare Medicare Supplement Anthem Medicaid (1) Anthem Medicare Advantage (2) BlueCard Program (non-anthem members) Local fully insured commercial members for whom Anthem is the secondary carrier Please follow the primary carrier s guidelines. (1) OrthoNet has been performing Utilization Management for Anthem Medicaid and individual Anthem Medicare Advantage members for some time

51 Physical and Occupational Therapy Utilization Management Providers excluded from the program Chiropractors Acupuncturists Massage Therapists Home Health Centers or Agencies Inpatient Skilled Nursing Facilities Settings excluded from the program Services rendered as part of an emergency room service Services rendered in a hospital inpatient setting Services rendered in an urgent care setting Services rendered as part of an observation room service Services rendered in a home setting Services rendered in a skilled nursing facility inpatient setting 51 51

52 Physical and Occupational Therapy Utilization Management Prior Authorization Requirements Initial evaluation and services rendered during the initial evaluation DO NOT require prior authorization Outpatient and office physical and occupational therapy services that are provided after the initial evaluation rendered November 1, 2015 and later require prior authorization through OrthoNet. Includes members already in a course of treatment that will receive services on or after November 1, Prior authorizations are at a visit level. An authorization is not a guarantee of payment. Coverage is subject to the terms and limitations of the members policy

53 Physical and Occupational Therapy Utilization Management The process Providers can contact Anthem Provider Services using the phone number on the back of the member s ID card for benefit information. Use Availity to view eligibility, benefits and limitations Providers will be informed whether the OrthoNet program applies to the member. OrthoNet will also have a list of the in-scope membership and will not provide prior authorization services for members who are out of scope. If providers using the Interactive Care Reviewer (ICR) to prior authorize an outpatient PT/OT service will receive a message referring the provider to OrthoNet. OrthoNet is available by phone or fax to process prior authorization requests for therapy to be rendered on or after November 1,

54 Physical and Occupational Therapy Utilization Management Availity Website Verify eligibility and benefits Select Physical or Occupational Therapy Benefits Click on the Coverage and Benefits Tab View any deductible, copay and/or coinsurance information View benefit limitations and remaining visits Availity is an independent company providing a wide variety of online tools that allow providers to access real-time information from multiple payers via one secure sign-on

55 Physical and Occupational Therapy Utilization Management The process Providers should submit requests for therapy visits in advance or within two business days of the PT/OT services using the OrthoNet Fax Request Form available on OrthoNet s website at The completed form and supporting clinical information should be faxed to OrthoNet s Medical Management Automated Fax Request line at beginning with November 1, 2015 date of service. The supporting clinical information may be sent on OrthoNet s PT/OT Initial Report Form, Functional Progress Chart or any form or clinical notes the provider has that supplies the same information. Prior authorizations are valid for 45 days from the date of service. Providers can check the status of the prior authorization by calling OrthoNet at

56 OrthoNet website Select Provider Choose Anthem under Health Plan Contracts o Choose Anthem BlueCross BlueShield (Commercial) 56 56

57 OrthoNet website Anthem BlueCross and BlueShield (Commercial) o Choose Wisconsin 57 57

58 OrthoNet website Frequently Asked Questions Forms o Anthem BlueCross BlueShield Therapy Request Form o PT/OT Initial Evaluation Report o PT/OT Initial Evaluation for Vestibular Dysfunction o Functional Progress Chart 58 58

59 Anthem Medicare Advantage (1) and Anthem Medicaid (BaderCare Plus) (2) Precertification Tools Access via Availity My Payer Portals Choose Anthem Medicare Advantage or Anthem Medicaid Provider Self Service (1) Available for Individual Medicare Advantage members. Alpha prefixes VOE, ZRB, VOT (2) Available for Anthem Medicaid members. Alpha prefix ZRA 59 59

60 Anthem Medicare Advantage (1) and Anthem Medicaid (BaderCare Plus) (2) Precertification Tools Click I Agree after viewing disclaimer 60 60

61 Medicare Advantage Precertification Tools Systematically navigated to the Medicare Advantage Provider Self Service Home page. Choose Precertification from the left menu 61 61

62 Medicare Advantage Precertification Tools Precertification Lookup Tool 62 62

63 Medicare Advantage Precertification Tools Precertification Lookup Tool continued Enter Market (State) Line of Business (Medicare Advantage) CPT Code or Term 63 63

64 Medicare Advantage Precertification Tools Precertification Lookup Tool continued Press Select to view description and requirements 64 64

65 Medicare Advantage Precertification Tools Request Precertification Select the type of request 65 65

66 Medicare Advantage Precertification Tools General Services Complete the Request Info tab Click the Authorization Type drop-down menu and select the type of admission. Type the requested date of service in the Authorization Date field or click the calendar icon to select the date. Click the Place of Service drop-down menu and select the appropriate place of service. Click the ID Type drop-down menu and select the specific ID type or All ID Types. Enter the ID number that corresponds with the ID type selected and click Find Member

67 Medicare Advantage Precertification Tools General Services continued Request Info tab continued o If multiple members are found during the search, select the correct Member Name from the list. o If the member is eligible, the member s information will display. o If no members are found, re-enter the information to ensure it was typed accurately or try a different ID type and repeat your search. If you still receive an error message, call Anthem Blue Cross and Blue Shield Provider Services at the number on the back of the member s ID card. Click Next

68 Medicare Advantage Precertification Tools General Services continued Complete the Provider Info tab Tax ID # drop-down menu o Only the Tax ID number associated with the user s credentials will be listed. Select Provider (choose requesting provider s name from the list.) Contact information Referring/Attending Provider Servicing Provider 68 68

69 Medicare Advantage Precertification Tools General Services continued Complete the Diagnosis tab Primary Diagnosis Treatment Type (choose appropriate treatment from drop-down menu) Procedure Code Notes 69 69

70 Medicare Advantage Precertification Tools General Services continued Complete the Supporting Files tab Browse and locate supporting clinical file. o MsWord, MsExcel, PDF and TIFF formats Attach to upload Repeat until all necessary files are attached Next 70 70

71 Medicare Advantage Precertification Tools General Services continued Complete the Review and Submit tab Review information and correct errors Print Review Copy Submit Auth Request Keep a Copy of confirmation number 71 71

72 Medicare Advantage Precertification Tools Request Precertification Step by step instructions on the Medicare Advantage Provider Home Page: Website Precertification Request Training 72 72

73 Links to more information Anthem public provider website links Precertification Guidelines Page Precertification (Tools) Page Medical Policy UM Guidelines Precert Requirements Local and BlueCard Page Working with Anthem Special Session Physical and Occupational Therapy Utilization Management Program Contact Us Page (WI Ready Reference Guide) Medicare Advantage Public Provider Home Page Medicaid Public Provider Home Page Medicare Advantage Website Precertification Request Training Medicaid Website Precertification Request Tutorial 73 73

74 Links to more information Interactive Care Reviewer training webinar registration link: AIM Specialty Health website: OrthoNet website: Availity website:

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76 Working with Anthem Subject Specific Webinar Series Please complete the Webinar Evaluation Survey Individuals completing the evaluation survey within 2 business days will be eligible for a Blue Prize package. Winner will be notified by within 3 business days Thank you for attending Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association