Sleep Solution for Magellan Complete Care of Virginia Members Provider Training Program for Sleep Management Presented By:
Magellan Healthcare 1 Program Agenda Sleep Disorders Our Program 1. Magellan Healthcare s Sleep Solution 2. Prior-Authorization Program 3. Clinical Information Request and Review 4. Prior-Authorization Process 5. Notification of Determination 6. Network Approach 7. Provider Tools and Contact Information Questions and Answers 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. 2
Sleep Disorders Sleep Disorders can exacerbate medical issues resulting in increased healthcare utilization when left untreated Untreated sleep disorders can contribute to worsening of medical conditions such as heart disease, high blood pressure, diabetes, etc. The impact of sleep disorders is gaining wider recognition Obstructive Sleep Apnea (OSA) affects 15-30 million people in the United States and is the most prevalent sleep disorder Other disorders include narcolepsy, periodic movement disorder, restless leg syndrome, parasomnia, etc. Magellan Healthcare s Sleep Solution Addresses growing demand for sleep-related services. 3
Magellan Healthcare s Sleep Solution for Magellan Complete Care of Virginia Manages utilization of sleep tests Ensures appropriate use of polysomnography based on clinical guidelines Reduces unnecessary repeat studies Encourages sleep assessments when needed due to the potential for other medical co-morbidities Promotes appropriate assessment setting Supports facility-based testing when appropriate 4
Magellan Healthcare s Prior Authorization Program August 1, 2017 Only non-emergent procedures performed in an outpatient setting (with the exception of Inpatient Musculoskeletal (MSK) Surgeries) require prior authorization with Magellan Healthcare Procedures Requiring Prior Authorization Excluded from Program: Procedures Performed in the Following Settings: Diagnostic Imaging MR, CT/CTA, PET, CCTA, Nuclear Cardiology/MPI, Stress Echo, Echocardiography Cardiac Interventions Catheterizations and Implantable Devices Musculoskeletal (MSK) Procedures Interventional Pain Management- Spinal Epidural Injections Facet Joint Injections Facet Joint Denervation/Neurolysis MSK Surgery (Inpatient and Outpatient) Lumbar Microdiscectomy Lumbar Decompression Lumbar Spine Fusion (Arthrodesis) Cervical Anterior Decompression with Fusion Single & Multiple Levels Cervical Posterior Decompression with Fusion Single & Multiple Levels Cervical Posterior Decompression (without fusion) Cervical Artificial Disc Replacement Cervical Anterior Decompression (without fusion) Radiation Oncology Management All Radiation Therapy for All Cancer All Other Conditions using Intensity Modulated Radiation Therapy Stereotactic Radiation Therapy and Proton Beam Sleep Studies Hospital Inpatient (excluding MSK Surgery) Observation Emergency Room/Urgent Care Facility 5
Sleep Management for Magellan Complete Care of Virginia Magellan Healthcare s sleep solution for MCC VA manages attended sleep assessments and treatment initiation/management services using prior authorization and clinical reviews The MCC-VA program does NOT manage home sleep tests (because this is not a covered benefit) or sleep treatment devices (e.g. CPAP machines) Authorized CPT Code Description Allowable Billed Groupings 94660 Sleep disorder treatment 94660 initiation and management 95811 Sleep study, attended 95782, 95783, 95805, 95807, 95808, 95810, 95811 6
List of CPT Procedure Codes Requiring Prior Authorization Review Claims/Utilization Review Matrix to determine CPT codes managed by Magellan Healthcare CPT Codes and their Allowable Billable Groupings Located on RadMD Defer to Magellan Complete Care of Virginia s Policies for Procedures not on Claims/Utilization Review Matrix INSERT HEALTH PLAN SPECIFIC MATRIX SCREEN SHOT 7
Responsibility for Authorization Ordering Provider Responsible for obtaining prior authorization Rendering Provider Ensuring that prior authorization has been obtained prior to providing service Recommendation to Rendering Providers: Do not schedule test until authorization is received 8
Prior Authorization Process Overview Algorithm Algorithm Submit Requests by Phone Ordering Physician Telephone Magellan Or Healthcare Online Through Magellan s RadMD Call www.radmd.com Center Information Online Through evaluated via algorithm RadMD and www.radmd.com medical records Claim Rendering Provider Performs Service Service Authorized 89
NIA s Clinical Foundation & Review Clinical Guidelines Are the Foundation Clinical guidelines were developed by practicing specialty physicians, literature reviews, and evidence base. Guidelines are reviewed and mutually approved by Magellan Complete Care and Magellan Healthcare Chief Medical Officers and clinical experts Clinical Algorithms collect pertinent information Algorithms are a branching structure that change depending upon the answer to each question Fax/Upload Clinical Information (upon request) When requested, the patient s medical record will be required for validation of clinical criteria before an approval can be made Clinical Review by NIA s Specialty Clinicians NIA reviews key clinical information to ensure Magellan Complete Care of Virginia members are receiving appropriate care based on their clinical condition Peer-to-Peer Discussion Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines. Our goal ensure that Magellan Complete Care members are receiving appropriate care 10
Patient and Clinical Information Required for Authorization GENERAL Includes things like ordering physician information, Member information, rendering provider information, requested examination, etc. CLINICAL INFORMATION Clinical information needs to explain the need for an attended sleep test, including: Patient symptoms, relevant patient characteristics, patient s current status and physical exam findings. Screening test results or reports from other diagnostic tests; if request is due to a failed Home Sleep Test, include documentation of results and issues. Contraindications to a Home Sleep Test, including the patient s relevant medical history. Refer to the Prior Authorization Checklists on RadMD for more specific information. 11
Requesting Clinical Information NIA may request patient s medical records/additional clinical information Providers may either submit medical records or contact our Nurse Reviewer with additional clinical information Medical records are preferred and are easy to upload via RadMD Helps ensure that patients receive the most appropriate, effective care 12
Magellan Healthcare to Ordering Provider: Request for Additional Clinical Information A fax is sent to the provider requesting medical records, 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 13
Submitting Additional Clinical Information/Medical Records to Magellan Healthcare Two ways to submit clinical information to Magellan Healthcare Via Fax Via RadMD Upload Use the Fax Coversheet (when faxing clinical information to Magellan Healthcare) Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call Center @ 1-800- 424-4524 Be sure to use the Magellan Healthcare Fax Coversheet for all transmissions of clinical information! 14
Prior Authorization Process Intake level Initial Clinical Review Physician Clinical Review Requests are evaluated using our clinical algorithm Requests may: 1. Approve 2.Require additional clinical review 3.Pend for clinical validation of medical records Nurses will review request and may: 1. Approve 2.Send to Magellan Healthcare s physician for additional clinical review* Physicians may: 1. Approve 2.Deny A peer to peer discussion is always available! 15
Notification of Determination Approval Notification Denial Notification Authorization Validity Period RBM, IPM, MSK Surgery, Cardiac and Sleep - 90 days from the date of the request Radiation Oncology = 180 days from the date of the request Appeal Instructions In the event of a denial, providers are asked to follow the appeal instructions provided in their denial letter 16
Magellan Healthcare s Re-review and Urgent/Expedited Authorization Process Re-review Process Re-Reviews will be allowed within 5 business days of initial denial determination Urgent Authorization Process If an urgent clinical situation exists outside of a hospital emergency room, please contact Magellan Healthcare immediately with the appropriate clinical information for an expedited review 1-800-424-4524 17
Using Magellan Complete Care of Virginia s Network Provider Network: Magellan Complete Care of Virginia will use their network of sleep assessment Providers/Facilities for delivering Sleep Management services to Magellan Complete Care of Virginia s membership 18
Claims How Claims Should be Submitted Rendering providers/imaging providers should send their claims directly to Magellan Complete Care of Virginia. Providers are strongly encouraged to use EDI claims submission. Check on claims status by logging on to the Magellan Complete Care website at: www.mccofva.com Claims Appeals Process In the event of a prior authorization or claims payment denial, providers may appeal the decision through Magellan Complete Care of Virginia Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification. 19
Provider Tools Provider Tools that Make it Easy for Providers to Partner with Magellan Healthcare Toll free authorization and information number 1-800-424-4524 Available Monday Friday 8am 6pm EST Interactive Voice Response (IVR) System RadMD Website Available 24/7 (except during maintenance) Different functionality for ordering and facility/place of service providers Request authorization and view authorization status Upload additional clinical information View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents 20
Ordering Provider: Getting Started on RadMD.com Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations. STEPS: 1. Click the New User button on the right side of the home page. 2. Select Physician s office that orders radiology exams 3. Fill out the application and click the Submit button. You must include your e-mail address in order for our Webmaster to respond to you with your Magellan Healthcare-approved username and password. NOTE: On subsequent visits to the site, click the Sign In button to proceed. 1 2 3 21
Rendering Provider: Getting Started on RadMD.com IMPORTANT 1 Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations. Designate an Administrator for the facility who manages the access for the entire facility. STEPS: 1. Click the New User button on the right side of the home page 2. Select Imaging Facility or Hospital that performs radiology exams 3. Fill out the application and click the Submit button. You must include your e-mail address in order for our Webmaster to respond to you with your Magellan Healthcare-approved username and password. NOTE: On subsequent visits to the site, click the Sign In button to proceed. 2 3 22
Dedicated Provider Relations Contact Information Magellan Healthcare Dedicated Provider Relations Manager: Name: Charmaine S. Everett Phone: 1-800-450-7281 ext. 32615 or at (410) 953-2615 Email: cseverett@magellanhealth.com Providing educational tools to Medical Specialty Ordering Providers and Facilities on processes and procedures. Magellan Complete Care of Virginia provider Service Department Phone: 1-800-424-4524 23
Confidentiality Statement for Providers The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan Complete Care of Virginia 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 Magellan Complete Care of Virginia and Magellan Health, Inc. 24
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