Aetna/Coventry Pennsylvania and West Virginia Physical Medicine Overview for Providers

Aetna/Coventry Pennsylvania and West Virginia Physical Medicine Overview for Providers

Aetna Physical Medicine Overview What: When: Who: Aetna will initiate a Utilization Management Prior Authorization Program for outpatient Physical Medicine Services All provider types will be required to obtain an authorization for identified Physical Medicine Codes The program includes both rehabilitative and habilitative care Program Start Date: September 1 st, 2018 Aetna/Coventry of PA and WV Includes all members except ASO and Out of Network Services 2

NIA Physical Medicine Program Agenda Our Program Prior Authorization Process and Overview Clinical Information Required Notification of Determination Provider Network Claims Provider Tools and Contact Information 3

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

NIA Facts NIA Facts Industry Presence Clinical Leadership Product Portfolio Providing Client Solutions since 1995 Magellan Acquisition (2006) Headquartered in Scottsdale, AZ Business supported by two National Call Operational Centers 78 Health Plan Clients serving 27.06 National Lives 15.57M Commercial; 1.45M Medicare; 10.04M Medicaid 41 states NIA Facts 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 Musculoskeletal Management (Surgery/IPM) Physical Medicine (Chiropractic Care, Speech Therapy, Physical and Occupational Therapies) Provider Profiling & Practice Management Analysis 5

6 Prior Authorization Process and Overview

NIA s Physical Medicine Prior Authorization Program Effective September 1, 2018, Aetna will begin partnering with NIA for the management of Physical Medicine Services. The NIA Call Center will be available beginning August 27, 2018 for prior authorization for dates of service September 1, 2018 and beyond. Any services rendered on and after September 1, 2018 will require authorization. Services Requiring Authorization Outpatient Physical Medicine Codes* Provider types that commonly use these codes include, but are not limited to Physical Therapists, Occupational Therapists, Chiropractors, and Physicians Excluded from Program Hospital ER, Inpatient, and Observation Status Acute Rehab Hospital Inpatient Skilled Nursing Facility Home Therapy *Code list available online at www.radmd.com and www.aetna.com/physicalmedicine 7

Physical Medicine Services Requiring Prior Authorization CPT Code Description 97012 Mechanical Traction Therapy 97014 Electric Stimulation Therapy 97016 Vasopneumatic Device Therapy 97018 Paraffin Bath Therapy 97022 Whirlpool Therapy 97024 Diathermy Treatment 97026 Infrared Therapy 97028 Ultraviolet Therapy 97032 Electrical Stimulation G0283 Electrical Stimulation S8948 Low Level Laser 97033 Electric Current Therapy 97034 Contrast Bath Therapy 97035 Ultrasound Therapy 97036 Hydrotherapy 97039 Unlisted Modality (Specify) 97110 Therapeutic Exercises 97112 Neuromuscular Reeducation 97113 Aquatic Therapy/Exercises 97116 Gait Training Therapy 97124 Massage 97139 Unlisted, Therapeutic Procedure 97140 Manual Therapy 97150 Group Therapeutic Procedures 97530 Therapeutic Activities CPT Code Description 97127 Cognitive Skills Development G0515 Cognitive Skills Development 97533 Sensory Integration 97535 Self-Care Management Training 97542 Wheelchair Management 97750 Physical Performance Test 97760 Orthotic(s) Management, Initial Encounter 97761 Prosthetic Training, Initial Encounter 97763 Orthotic/Prosthetic, Subsequent Encounter 98925 Osteopathic Manipulative Treatment (OMT), one or two body regions 98926 OMT, three to four body regions 98927 OMT, five to six body regions 98928 OMT, seven to eight body regions 98929 OMT, nine to ten body regions 98940 Chiropractic Manipulative Treatment (CMT), one or two spinal regions 98941 CMT, three or four regions 98942 CMT, five regions 98943 CMT, extraspinal, one or more regions Evaluation codes do not require authorization. Only specified codes require authorization. 8

Physical Medicine CPT Codes Requiring Prior Authorization with Allowable Billed Groupings Parent CPT Code** Description Allowable Billed Groupings* 98940 MANIPULATION 98940, 98941, 98942, 98943, 98925*, 98926*, 98927*, 98928*, 98929* 97110 ACTIVE PROCEDURES 97110, 97112*, 97113, 97116, 97150*, 97530 97535* SELF CARE, COGNITIVE, SENSORY SKILLS 97127, G0515, 97533, 97535, 97542 97140 MANUAL INTERVENTIONS 97124, 97140 97035 MODALITIES 97012, 97014, 97016*, 97018*, 97022, 97024, 97026*, 97028, 97032, 97033, 97034, 97035, 97036, 97039*, 97139*, G0283, S8948* 97760* ORTHOTIC/PROSTHETICS 97760, 97761, 97763 97750* PHYSICAL PERFORMANCE TEST 97750 *Indicates entire billable grouping or individual code that is not included on the Pennsylvania Chiropractic Fee Schedule and is not payable for Chiropractic providers. **Parent CPT code is the code that will appear on the authorization with the allocated number of units. Provider may bill the allowable grouped codes as appropriate under that authorization. 9

Responsibility for Prior Authorization Provider Responsibilities Verify member s benefits by contacting Aetna s Customer Service Department. Obtain an authorization for physical medicine services prior to rendering and/or within 5 business days of the evaluation if services were rendered during the evaluation or prior to requesting an authorization* Ensure that prior authorization has been obtained prior to rendering services beyond the evaluation (or within the permitted timeframe)** *Failure to obtain an authorization may result in denied claims. **NIA recommends that you do not schedule any additional physical medicine services beyond the initial evaluation until authorization is obtained. 10

Authorization Process Overview Prior Authorization Process After the evaluation has been completed* and/or a plan of care established, request authorization for the services/codes to be rendered. Log in to RadMD or call NIA s Call Center prior to OR within 5 business days of rendering the service. Algorithm Clinical Algorithm www.radmd.com Claim Provider Performs Service Documentation Submitted, Reviewed and Decision Rendered Treatment may be authorized and/or you may be instructed to submit clinical for validation upon completion of the evaluation. *Evaluation codes do not require authorization 11

12 Clinical Information Required

Clinical Decision Making and Algorithms Clinical guidelines are reviewed and mutually approved by Aetna and NIA Chief Medical Officers and senior clinical leadership. NIA s algorithms and medical necessity reviews collect key clinical information to ensure that Aetna s members are receiving appropriate outpatient rehabilitative and habilitative physical medicine services. NIA issues authorizations in accordance with Aetna s benefit guidelines, NIA internally developed guidelines, commercially licensed guidelines and Apollo Licensed Guidelines for physical medicine services. NIA Clinical Guidelines are available on www.radmd.com : Select the Solutions tab at the top of the page Click on Physical Medicine to be directed to the general guidelines page To access Aetna s specific criteria online at www.radmd.com : Sign In with User name and passcode At Menu Options, click link to Clinical Guidelines Click on the Health Plans selection on the menu bar. Scroll down the page to locate your specific health plan name Click on the link to open the pdf document. 13

Patient and Clinical Information Required for Authorization GENERAL INFORMATION AT INTAKE Provider information and type, member information, date of initial evaluation, types of service codes requested. CLINICAL INFORMATION AT INTAKE Treating Diagnosis and body region being treated, date of onset. Surgery date and procedure performed (if applicable) Brief medical history and summary of previous therapy (if any) Functional Outcome Tool and Scores; Level of Impairment CLINICAL RECORD CONTENT *NEEDED FOR CLINICAL VALIDATION Baseline evaluation including current and prior functional status Objective tests and measures appropriate to the discipline of therapy, standardize test with raw score, functional outcome assessments and scores School programs, including frequency and goals (for habilitative services) Treatment prognosis and rehab potential. Treatment Plan including interventions planned, specific functional goals that are measurable, sustainable and timespecific *Refer to the Clinical records checklist on RadMD for more specific information 14

NIA to Provider: Request for Additional 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 15

Submitting Additional Clinical Information/ Medical Records to NIA Two ways to submit clinical information to NIA Via RadMD Upload Via Fax Use the Fax Coversheet (when faxing clinical information to NIA ) Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call Center : Coventry: PA 1-866-326-6303 WV 1-800-424-5687 Aetna 1-866-842-1542 Be sure to use the NIA Fax Coversheet for all transmissions of clinical information! 16

Prior Authorization Process Intake Level Initial Clinical Review Subsequent Requests Requests are evaluated using our clinical algorithms Requests may: 1.Approve 2.Require additional clinical review and Pend for clinical validation of medical records Peer reviewer (therapist, chiropractor, physician, etc.) will review request and may: 1.Approve 2.Deny A peer to peer discussion is always available! Occurs beyond the initial authorization Requests can be made by uploading records on RadMD or faxing in the request using the fax coversheet provided with the initial authorization 17

Subsequent Requests If additional units are requested, a new type of intervention (new billable grouping) or date extension is needed, clinical validation is required Request can be made via RadMD or Fax using previously provided fax coversheet or print a new one A new request is not necessary. It is considered an update to the existing authorization. 18

Peer to Peer Reviews A peer reviewer may reach out during the review process to discuss the plan of care and/or treatment interventions being utilized. This may or may not be in the face of any adverse determination, but allows reviewers to gain insight into the providers clinical judgement and/or discuss any deviations from evidence based practice. A formal peer-to-peer, with one of our specialty matched peer reviewers, is offered in the face of any adverse determination recommendation, prior to finalizing the denial. NIA will reach out to the provider via phone and fax to offer them an opportunity to discuss this case and/or submit additional clinical information that was not previously reviewed. If the provider is not able to conduct a Peer to Peer at the time NIA reaches out, they may schedule one at a more convenient time by calling NIA: Coventry PA 1-866-326-6303 WV 1-800-424-5687 Aetna 1-866-842-1542 19

Summary Physical Medicine Points Only specified codes require authorization, evaluation codes are NOT included in this list of codes. Authorization is required for all provider types billing these physical medicine codes If multiple provider types are requesting services, they will each need their own authorization (i.e. PT and OT services) The requestor will be asked a series of questions to determine if clinical validation is required or if an authorization can be issued immediately All subsequent requests require clinical validation. Providers can either upload or fax this information for review An authorization will consist of a billable grouping, number of units for each approved grouping and a validity period. Authorizations will be issued using a parent code to allow flexibility in the provider s treatment plan. Providers must bill the appropriate code that matches the actual services rendered 20

21 Notification of Determination

Validity Period and Notification of Determination Approval Notification Denial Notification Authorizations will include the type and volume of codes approved and a validity period with which to use those codes in If additional codes (volume or service type) are needed, a subsequent request must be submitted The approval notification will include a fax coversheet that can be used for any subsequent requests Notifications will include an explanation of what services have been denied and the clinical rationale for the denial A peer to peer discussion will always be offered prior to issuing an adverse determination A reconsideration time frame may be available and can be initiated by a peer discussion or by submitting additional clinical information Information on how to proceed with a complaint or appeal will be included in the notification 22

23 Network

Provider Network and Benefit Structure Provider Network: Aetna s network of providers including Therapists, Chiropractors and Physicians will be used for the Physical Medicine Program. Benefit Structure: This Physical Medicine Program does not impact the current benefit structure including any covered services exclusions or benefit limits. Please reference the Provider and Member Manuals for additional information or contact Aetna s Provider Service Department for any Benefit questions. 24

25 Claims

Processing of Claims How Claims Should be Submitted Claims Appeals Process Providers will continue to submit their claims to Aetna Providers should not submit claims until after an authorization is obtained to avoid denial of payment for nonauthorization Providers are strongly encouraged to use EDI claims submission In the event of a prior authorization or claims payment denial, providers may appeal the decision through Aetna Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification. 26

27 Provider Tools and Contact Information

Provider Tools Toll free authorization and information number: Coventry: PA 1-866-326-6303 WV 1-800-424-5687 Aetna 1-866-842-1542 Available 8:00 a.m. 8:00 p.m. EST Interactive Voice Response (IVR) System for authorization tracking RadMD Website Available 24/7 (except during maintenance) Request authorization and view authorization status Upload additional clinical information View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents 28

Registering on RadMD.com Ordering Provider: Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations. 1 STEPS: 1. Click the New User button on the right side of the home page. 2. Select Physician s office that orders procedures 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 NIA-approved user name and password. NOTE: On subsequent visits to the site, click the Sign In button to proceed. 2 3 Offices that will be both ordering and rendering should request ordering provider access this will allow your office to request authorizations on RadMD and see status of those authorization request. 29

Rendering Provider: IMPORTANT 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. 1 2 2. Select Facility/office where procedures are performed 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 NIA -approved user name and password. NOTE: On subsequent visits to the site, click the Sign In button to proceed. 3 If you have multiple staff members entering authorizations and you want each person to be able to see all approved authorizations, they will need to register for a rendering username and password. The administrator will have the ability to approve rendering access for each employee. This will allow users to see all approved authorizations under your organization. 30

Dedicated NIA Provider Relations Manager for Aetna Providers: Aetna/Coventry West Virginia: NIA Dedicated Provider Relations Manager: April Sabino Phone: 1-800-450-7281, ext. 31078 Email: ajsabino@magellanhealth.com Aetna/Coventry Pennsylvania: NIA Dedicated Provider Relations Manager: Lori Fink Phone: 1-800-450-7281, ext. 32621 Email: lafink@magellanhealth.com 31

Confidentiality Statement The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to NIA 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 Health Services, Inc.

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