HMSA 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 Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. 2

Magellan Healthcare Program Agenda 1. Our Program Authorization Process Other Program Components Provider Tools and Contact Information 2. RadMD Demo 3. Questions and Answers

A Unique Vision of Care As the nation s leading specialty health care management company, we deliver comprehensive and innovative solutions to improve quality outcomes and optimize cost of care. >20% clinical disapproval rates 4

Magellan Healthcare Highlights Specialty Solution Facts Industry Presence Clinical Leadership Product Portfolio Providing Client Solutions since 1995 Magellan Acquisition (2006) Columbia, MD with 700 National Magellan Healthcare Employees Business supported by two National Call Operational Centers 79 Health Plan Clients serving 26.68M National Lives 16.16M Commercial; 1.28M Medicare; 9.25M Medicaid 36 states Strong panel of internal Clinical leaders client consultation; clinical framework Supplemented by broad panel of external clinical experts as consultants (for guidelines) Advanced Diagnostic Imaging Cardiac Solutions Radiation Oncology Ob Ultrasound Genetic Testing Musculoskeletal Management (Surgery/IPM) Chiropractic Care, Speech Therapy, Physical and Occupational Therapies Sleep Management Emergency Department Clinical Decision Support Provider Profiling & Practice Management Analysis URAC Accreditation & NCQA Certified 5

Magellan Healthcare s Prior Authorization Program Procedures Performed on or after 1/1/2014 Require Prior Authorization Outpatient/Office Interventional Pain Management (IPM) Spine Procedures Inpatient and Outpatient Lumbar Spine Surgery Spinal Epidural Injections Paravertebral Facet Joint Injections or Blocks Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis) Sacroiliac Joint Injections Excluded from Program-Interventional Pain Management (IPM) Procedures Performed in the Following Settings: Hospital Inpatient Observation Room Emergency Room/Urgent Care Facility Lumbar Microdiscectomy Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy) Lumbar Spine Fusion (Arthrodesis) With or Without Decompression Single & Multiple Levels Excluded from Program- Surgeries Performed in the Following Settings: Emergency Surgery admitted via the Emergency Room 6

List of CPT Procedure Codes Requiring Prior Authorization Review Utilization Review Matrix to determine CPT codes managed by Magellan Healthcare CPT Codes and their Allowable Billable Groupings Located on RadMD Defer to HMSA s Policies for Procedures not on Utilization Review Matrix 7

Responsibility for Authorization Ordering Providers Responsible for obtaining prior authorization Facility/Place of Service Ensuring that prior authorization has been obtained prior to providing service 8

Prior Authorization Process Overview Algorithm Submit Requests by Phone Ordering Physician Or Online Through RadMD www.radmd.com Information evaluated via algorithm and medical records Claim Rendering Provider Performs Service Service Authorized 9

Patient and Clinical Information Required Information for Authorization GENERAL Includes things like ordering physician information, member information, place of service, requested procedure, etc. SPECIAL INFORMATION Spinal Surgeries: Only one authorization request per surgery. Each interventional pain management procedure performed requires a prior authorization; Magellan Healthcare does not pre-approve a series of epidural injections. Date of Service is required. CLINICAL INFORMATION Clinical Diagnosis Physical exam findings and patient symptoms (including findings applicable to the requested procedure) Date of onset of pain or exacerbation. Duration of patient s symptoms. Conservative treatment modalities completed, duration, and results (e.g., physical therapy, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and/or medication) Date and results of prior interventional pain management procedures, where applicable. Diagnostic imaging results, where applicable. Preliminary procedures already completed (e.g., lab work, scoped procedures, referrals to specialist, specialist evaluation) 10

Magellan Healthcare s Clinical Foundation & Review Clinical Guidelines Are the Foundation Clinical Algorithms collect pertinent information Fax/Upload Clinical Information (upon request) Clinical Review by Magellan Healthcare s Specialty Experts Peer-to-Peer Discussion Clinical guidelines and algorithms: Developed by practicing specialty physicians Evidence based Literature review Reviewed and mutually approved by HMSA and Magellan Healthcare s Chief Medical Officers and Clinical Specialty Experts Magellan Healthcare reviews key clinical information to ensure that HMSA members are receiving appropriate care prior to more invasive procedures being performed. Magellan Healthcare has a specialized clinical team focused on musculoskeletal care. Peer-to-peer discussions are offered and scheduled for any request that does not meet medical necessity guidelines. Our Goal ensure that HMSA members are receiving appropriate musculoskeletal care. Clinical Guidelines available on: www.radmd.com http://1radmd.com/solutions-painmanagement-solutions.aspx 11

Magellan Healthcare to Physician: Request for Clinical Information A fax is sent to the provider detailing what clinical information that is needed, 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 12

Submitting Additional Clinical Information/Medical Records to Magellan Healthcare Two ways to submit clinical information to Magellan Healthcare Via Fax Via RadMD Upload Coversheets are sent with all requests for clinical information Coversheets can also be printed from RadMD or requested via the Call Center at 1-866-306-9729 Please use the Magellan Healthcare Fax Coversheet for all transmissions of clinical information! 13

Clinical Specialty Team: Focused on MSK Specialized Clinical Team IPM Reviews Initial Clinical Review performed by Magellan Healthcare Neurology Team Nurses Clinical Specialty Team Clinical specialties supporting IPM include: anesthesiology, orthopedic spine surgery, neurology, neurosurgery, and pain specialists Surgery Concierge Team will proactively outreach for additional information, reconsiderations and to schedule peer-to-peer session. MSK Surgery Reviews Nurse will assemble surgery cases and reach out for clinical information as needed prior to sending to surgeon reviewer. Only orthopedic surgeons or neurosurgeons conduct clinical reviews and peerto-peer discussion on surgery requests. 14

Notification of Determination Pre-certification Validity Period 90 days from the date of service; if no date of service is given, then 90 days from the date of request. 15

Adverse Determination Options Reconsideration/Reopen Via Magellan Healthcare only 16 Commercial Plan (Reconsideration) 1 opportunity within 30 calendar days of Magellan's determination date QUEST Integration Med-QUEST does not allow for re-review by HMSA or Magellan before Appeal timeframe of 30 days has passed If within 30 days from date of denial determination, follow Appeal process Beyond 30 days from date of denial determination, new case CAN be submitted for same procedure HMSA Akamai Advantage Plan (Re-open) CMS mandates request to be in writing using the Re-open Letter Contact Magellan Call Center or HMSA for a copy of a Re-open Letter Timeframes are based on re-open reason Within 1 year of denial date for any reason Within 4 years of denial date for good cause At any time if the denial was due to a clerical error NOTE: If the above criteria are not met, follow the appeal process with HMSA.

Adverse Determinations Options (2) Appeal Request at any time after adverse determination Request via HMSA only Phone: 948-5090 on Oahu or 1 (800) 426-2085 toll-free E-mail: appeals@hmsa.com Available for ALL lines of business Refer to member s denial letter for the appropriate appeal process and appeal timeframe 17

Peer to Peer Peer to Peer (P2P) reviews Clinician from ordering physician s office can discuss a request with Magellan reviewer Can be done at any time Discuss clinical rationale for request prior to a determination Can occur after a decision has been made. Pre determination P2P (Prior to determination made) If ordering physician would like to discuss the request If ordering physician feels submitted clinical information might not fully state the medical necessity of the patient s condition 18

Peer to Peer (2) Post determination (After determination has been made) A Peer to Peer may occur after a decision has been made and may result in an overturn of a denial without the need for a formal appeal. Commercial P2P can result in an overturn IF within 30 calendar days of denial Clinical evidence from the patient s medical record may still be required to be faxed in. Magellan reviewer will advise if needed QUEST Integration P2P is consult only while the case is open Advice can be given for HMSA formal appeal process if applicable HMSA Akamai Advantage P2P is consult only Advice for the HMSA formal appeal process if applicable For administrative errors (wrong study originally requested, etc.), a new decision can be made but only with a completed and signed re-open letter 19

Akamai Advantage Re-open Letter 20

Magellan Healthcare s Urgent/Expedited Authorization Process Urgent/Expedited Authorization Process If an urgent clinical situation exists (outside of a hospital emergency room), please call Magellan Healthcare immediately. The number to call to obtain a prior authorization is 1-866-306-9729 21

Using HMSA s Network HMSA will use their network of Pain Management Physicians, Surgeons, Hospitals, Surgery Centers and In-Office Providers as it s preferred providers for delivering Outpatient Interventional Spine Pain Management Services and select Inpatient and Outpatient Surgeries to HMSA members throughout Hawai i. 22

Summary Interventional Pain Management (IPM) Points Injections in all regions of spine are managed Date of Service is required for all requests Each IPM procedure must be prior authorized No series of epidural injections Specialty Nurses and Physicians will review IPM requests 23

Summary Musculoskeletal Surgery Points Inpatient and outpatient non-emergent surgeries require prior authorization Spine Surgery: Is focused on lumbar and/or cervical spine surgeries For spine surgeries, only one authorization request per surgery Example: Lumbar Fusion authorization includes decompression and instrumentation procedures. Specialized Orthopedic Surgeons or Neurosurgeons will review surgery requests Date of service is required 24

Contact Information Toll-free authorization and information number 1 (866) 306-9729 Available Monday through Friday, 6 a.m. to 6 p.m. Hawai i time Interactive voice response (IVR) system for authorization tracking Fax additional clinical information to 1 (800) 784-6864 toll-free RadMD website available 24/7 Request authorization (ordering providers only) and view authorization status Upload additional clinical information View clinical guidelines, frequently asked questions (FAQs), and other documents 25

Magellan Healthcare Website www.radmd.com RadMD Functionality varies by user: Rendering Provider Views approved authorizations for their facility. Ordering Provider s Office View and submit requests for authorization. Online Tools Accessed through www.radmd.com: Magellan Healthcare s Clinical Guidelines Frequently Asked Questions Quick Reference Guides RadMD Quick Start Guide Utilization Matrices 26

RadMD Menu Options 27

Important Contact Information Magellan Dedicated Hawai i-based Resource Name: Laurie Kim Director, Provider Relations & Account Management Hawai i Phone: 808.626.5704 E-mail: lekim@magellanhealth.com HMSA Provider Relations/Customer Service Phone: 808.948.6330 on Oahu or 1.800.790.4672 toll-free Where do I get a copy of the Magellan/HMSA clinical guidelines? How do I find the educational documents? Where/how do I sign up for RadMD 28

Confidentiality Statement for Educational Presentations 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 Health, Inc. The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to HMSA 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 HMSA and Magellan Health, Inc. 29

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