Radiation oncology prior authorization
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1 Radiation oncology prior authorization
2 Prior authorization (PA) decision tree Are you ready to deliver services to an Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan, member? Yes No Contact AIM Specialty Health (AIM) or Contact HealthKeepers, Inc. or AIM reviews PA requests for and planning services under the umbrella of certain modalities. AIM will review for the indicated modality as well as appropriate related codes. If you are only requesting PA for planning codes, and you are not yet ready to request PA for codes or the radiation therapy is being performed as part of an inpatient admission, you may request approval by contacting HealthKeepers, Inc.
3 AIM radiation oncology modality-based PA Providers must request the primary modality (tier one) from AIM in order to receive PA for any of the related lower-tier codes (tier two or three). Delivery: 1. Primary grouper 2. Grouper ID 3. Included codes 3
4 AIM radiation oncology modality-based PA: intensity-modulated radiation therapy (IMRT) Scenario one In this scenario, AIM is able to process the PA request because the primary code (77385) has been requested and the provider is ready to deliver the service. PA for code requested: 1. Primary grouper 2. Grouper ID 3. Included codes Provider calls AIM and requests PA for IMRT code During the same call, the provider should request PA for IMRT planning code and related treatment codes (77338 and 77427). 4
5 AIM radiation oncology modality-based PA: IMRT (cont.) Scenario two In this scenario, the provider is not ready to deliver services and does not request PA for the primary modality code (77385), so AIM is not able to process the request. PA for code not requested: 1. Primary grouper 2. Grouper ID 3. Included codes The provider calls AIM and requests PA for IMRT-related planning code The provider is not ready to deliver services and doesn t request PA for primary modality code AIM informs the provider that they authorize services based on of a treatment modality (a grouping of codes/package of services). In order to request PA for and related codes, AIM requests the provider contact them when they are ready to deliver services.* * PA requests for planning codes only should be made through HealthKeepers, Inc. 5
6 Primary modality brachytherapy 1. Primary grouper Grouper ID Q3001 handling handling calculation Retina Uterine/ vaginal Pelvic Penile tumor Biliary tract Esophagus Head/ neck Bronchoscopy Muscle/ soft tissue Breast 3. Included codes calculation calculation Uterine/ vaginal Uterine/ vaginal G Breast Breast Providers must request the primary modality from AIM (tier one) in order to request PA for any of the related lower-tier codes (tier two or three). PA requests for planning codes alone should go through HealthKeepers, Inc. 6
7 Thank you HealthKeepers, Inc. is a health plan that contracts with both Medicare and the Virginia Department of Medical Assistance Services to provide benefits of both programs to enrollees. HealthKeepers, Inc. is an independent licensee 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. AIM Specialty Health is a separate company providing utilization review services on behalf of HealthKeepers, Inc. AVADPEC March MUPENMUB 12/14/2016 7
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