EVIDENCE-BASED HEALTHCARE SOLUTIONS CareCore National Musculoskeletal CARECORE NATIONAL Management RADIOLOGY Program Physical BENEFIT Medicine MANAGEMENT and Therapy PROPOSAL Prepared for Prepared for October 23, 2009 December 19, 2013
TABLE OF CONTENTS Notification and Pre-Authorization FAQs... 4 What services are managed through the Physical Medicine and Therapy UM Program?.. 4 Which Oscar Insurance members are included in the UM Program?... 4 What is a Notification?... 4 What are the Notification submission requirements?... 4 What is a Treatment Request?... 4 What are the pre-authorization requirements for the UM Program?... 5 Will pre-authorizations specify the number of services/units approved?... 5 When I submit a Notification, will I know if a Treatment Request is also required?... 5 What is an Approved Time Period?... 5 Why are Approved Time Periods limited to 30-days?... 5 Can I use my own forms when requesting authorization?... 5 What do I enter as the "Start Date" on my Notifications or Treatment Requests?... 5 How far in advance can I submit a Treatment Request?... 6 Can I include Durable Medical Equipment (DME) supplies on an authorization request to CareCore? 6 What is the timeframe for a case to go through the Treatment Request review process?. 6 Will the clinical reviews be done by a practitioner of the same discipline?... 6 Is peer-to-peer consultation available?... 6 How can I track the status of my Treatment Requests?... 7 Can I request more treatment after my Approved Time Period expires?... 7 Can I extend the End Date of an authorization if I didn't use all the approved visits?... 7 Can I file an appeal for cases that have been denied or partially denied?... 7 Are the clinical criteria available for review?... 7 Will separate authorizations be required for a patient with two concurrent diagnoses?... 7 Page 2 of 8
If a member goes to a new practitioner for services, will a new Notification be required?.. 7 If a primary care provider (PCP) refers a patient, will that make any difference in the approval? 8 Who do I call to verify member eligibility?... 8 Where do I submit claims?... 8 Does the authorization number need to be on the claim?... 8 Page 3 of 8
Notification and Pre-Authorization FAQs All Physical Medicine and Therapy Networks What services are managed through the Physical Medicine and Therapy UM Program? The Physical Medicine and Therapy UM Program manages outpatient services for: Acupuncture Chiropractic Care Physical Therapy Massage Therapy Occupational Therapy Pain Management Which Oscar Insurance members are included in the UM Program? Please find detailed information on the Physical Medicine section of the Oscar Insurance website. What is a Notification? A Notification is the required information submitted to CareCore informing Oscar Insurance that a member is starting care. This Notification consists mostly of patient demographic information. The Notification allows for claims payment; the number of visits payable vary based on each request. What are the Notification submission requirements? All physical medicine/therapy practitioners must submit a Notification within seven days of the initial evaluation. You may also need to submit a Treatment Request to obtain preauthorization for the treatment episode. The Notification or a Treatment Request may be submitted by the servicing practitioner or his/her office staff. The preferred method to submit the Notification information is online at www.carecorenational.com. Online submissions are available 24/7. Notifications can also be submitted by phone at 855-252-1118 between 7 a.m. and 7 p.m. local time Monday through Friday. What is a Treatment Request? The Treatment Request is a tool required for submission of patient and practitioner information for medical necessity review. Treatment Requests are condition-specific based on the type of service requested Page 4 of 8
The preferred method to submit Treatment Requests is online at www.carecorenational.com. With online submission, you may receive an instantaneous review determination for your Treatment Request. You may also call CareCore at 855-252-1118 7 a.m. through 7 p.m. local time Monday through Friday. What are the pre-authorization requirements for the UM Program? If you are an Oscar Insurance participating-practitioner, you may be required to submit a Treatment Request to obtain pre-authorization for all treatment after the initial visit. Will pre-authorizations specify the number of services/units approved? Yes. When visits are authorized based on a Notification or Treatment Request, the authorization will provide the number of approved services for those visits. When I submit a Notification, will I know if a Treatment Request is also required? Yes. After your initial submission, CareCore will prompt you to complete a Treatment Request if one is required at the time you submit your Notification. What is an Approved Time Period? The Approved Time Period is the time period (duration) available to use approved visits. Visits must be spread throughout the authorized period to avoid a gap in care at the end of the Approved Time Period. Why are Approved Time Periods limited to 30-days? Medical necessity authorizations are typically approved for a 30-day period, allowing the servicing practitioner to assess the patient s response to treatment. Can I use my own forms when requesting authorization? No. To ensure that clinical peer reviewers receive necessary and complete information, and to make consistent clinical determinations, the Treatment Request is required for medical necessity reviews. What do I enter as the "Start Date" on my Notifications or Treatment Requests? For initial Notifications, the Start Date is the patient's initial evaluation date. Under the UM program, your first Treatment Request Start Date will be the seventh visit if you received an initial authorization for six "waiver" visits when you submitted your Notification. Page 5 of 8
For continuing care requests, the Start Date is the first visit that requires pre-authorization after the previous Approved Time Period expiration. Do not enter the first date of the patient's treatment episode for continuing care requests. How far in advance can I submit a Treatment Request? Submit Treatment Requests no more than seven days prior to the proposed Start Date. Requesting care too far in advance does not allow you to report up-to-date examination findings. The objective findings date reported on your Treatment Request should be within seven days of your requested Start Date. To avoid a delay in receiving a review determination, provide current clinical findings, paying particular attention to how you document the patient s progress with the services you have already provided. Can I include Durable Medical Equipment (DME) supplies on an authorization request to CareCore? You may document that a patient requires specialized DME equipment; however, orthotics, DME and supplies will not be authorized by CareCore. Follow the normal Oscar Insurance process for all DME. What is the timeframe for a case to go through the Treatment Request review process? If medical necessity can be established based on evidence-based criteria, visits will be pre-authorized at the time of your Treatment Request submission. When you submit online, this pre-authorization will be instantaneous. When a clinician review is required, CareCore's review determination timeframes will comply with applicable regulations. The turnaround times are dependent upon all necessary information being provided to CareCore. If there is insufficient information to make a determination, CareCore will fax you a hold letter indicating the information that is still required. The surest way to avoid this scenario is to have updated clinical information available before contacting CareCore. Will the clinical reviews be done by a practitioner of the same discipline? Yes. Requests requiring clinical evaluation will be reviewed by appropriate specialty clinicians. For example, chiropractors review Treatment Requests for chiropractic services. All adverse determinations for therapy services are physician reviewed. Is peer-to-peer consultation available? Yes. When there is a request for a peer-to-peer conversation, CareCore makes an effort to immediately transfer the call to an available CareCore clinical reviewer. When one is not available, a scheduled call-back is offered at a time that is convenient for your practice. These timeframes will comply with applicable regulation and law. Page 6 of 8
How can I track the status of my Treatment Requests? To check the status of a case, log on to www.carecorenational.com and select Authorization Lookup. Can I request more treatment after my Approved Time Period expires? Yes. If you believe a patient will require more visits after the Approved Time Period expires, submit an updated Treatment Request for continuing care. Keep in mind that Treatment Request periods cannot overlap. Therefore, be sure the Start Date of your request for continuing care is after the expiration of your previous authorization. Can I extend the End Date of an authorization if I didn't use all the approved visits? Yes. CareCore will approve one extension per Approved Time Period up to 30 days. Can I file an appeal for cases that have been denied or partially denied? We recommend that you utilize the reconsideration process before filing a formal appeal. Reconsiderations are completed via the telephone and through peer-to-peer consultations as applicable. If the initial decision is upheld, then the next step is a first-level appeal. The review determination letter will provide instructions for appealing a medical necessity decision, including your right to submit additional information. Are the clinical criteria available for review? Yes. Evidence-based criteria will be available online through the CareCore National practitioner web portal at www.carecorenational.com. Will separate authorizations be required for a patient with two concurrent diagnoses? No. Each medical necessity review considers all reported diagnoses for the patient. However, separate Notifications and Treatment Requests are required for patients receiving care from multiple practitioners or specialties (e.g., for a patient receiving both physical therapy and acupuncture therapy). If a member goes to a new practitioner for services, will a new Notification be required? Yes. When a member changes to a treating practitioner who is not within the same practice, a new Notification submission is required. The Treatment Request requirement for medical necessity review will be based on the new treating practitioner's UM Program assignment. Page 7 of 8
If a primary care provider (PCP) refers a patient, will that make any difference in the approval? No. There are no changes in requirements for Oscar Insurance members in regards to physician referrals. Authorizations are based on medical necessity and evidence-based criteria. Who do I call to verify member eligibility? Follow your normal Oscar Insurance process for eligibility verification. Where do I submit claims? Follow your normal Oscar Insurance process for claims submission. Does the authorization number need to be on the claim? No. There are no changes for submitting a claim. Follow the standard Oscar Insurance claims filing process. Page 8 of 8