Magellan Healthcare1 Medical Specialty Solutions

Magellan Healthcare1

Medical Specialty Solutions

PROVIDER TRAINING/PRESENTED BY:

NAME:

DATE:

1 NATIONAL IMAGING ASSOCIATES, INC. IS A SUBSIDIARY OF MAGELLAN HEALTHCARE, INC.

Magellan Healthcare Training Program

2

Introduction to Magellan Healthcare

Our Program

1. Expanded Authorization Program

2. Clinical Validation of Records (CVR) process

3. Authorization Process

4. Provider Tools and Contact Information

Questions and Answers

Magellan Healthcare Program Agenda

3

Clinical Validation Program

4

Effective August 1, Capital BlueCross is expanding its partnership with Magellan Healthcare to implement a Clinical Validation of Records (CVR) process. Outpatient services managed and authorized by Magellan Healthcare that will be included in the CVR process are:

• Fractional Flow Reserve CT• Myocardial Perfusion Imaging• PET Scan• Select CTs • Select MRIs

5

Capital BlueCross will expand its partnership withMagellan Healthcare

Magellan Healthcare Prior Authorization Program

• Emergency room• Hospital inpatient• Observation• Surgery center

Procedures performed in the following settings

are excluded:

6

List of CPT Procedure Codes Requiring Prior Authorization

• CPT codes and their allowable billable groupings

• Defer to Capital BlueCross policies for procedures not on claims/utilization review matrix

• Located on RadMD

• Review claims/utilization review matrix to determine CPT codes managed by Magellan Healthcare

7

CVR Program Effective August 1

Why CVR?

• Reduce unnecessary imaging and support the requirements of program integrity from CMS. These are key goals of our relationship with Magellan Healthcare.

• Ensure that patients receive the most appropriate, effective care and understand physician ordering patterns so the utilization management process can be customized—achieved by auditing the clinical record.

• Provide greater protection to patients and payers of healthcare services.

Also:

• Data indicates that one third of all imaging tests are noncontributory.

• Discrepancies exist in clinical information provided orally versus the patient’s medical records.

• Reasons given for the test are not supported.

9

Magellan Healthcare’s Clinical Review Process

10

Authorized CPT Code

Description Allowable Billed Groupings

70450 CT Head/Brain 70450, 70460, 70470

70490 CT Soft Tissue Neck 70490, 70491, 70492

70551 MRI Brain 70551, 70552, 70553

71250 CT Chest 71250, 71260, 71270, G0297

72131 CT Lumbar Spine 72131, 72132, 72133

72141 MRI Cervical Spine 72141, 72142, 72156

72146 MRI Thoracic Spine 72146, 72147, 72157

72148 MRI Lumbar Spine 72148, 72149, 72158

72192 CT Pelvis 72192, 72193, 72194

72196 MRI Pelvis 72195, 72196, 72197

73221 MRI Upper Extremity Joint 73221, 73222, 7322373720 MRI Lower Extremity 73718, 73719, 73720, 73721, 73722, 73723

73721 MRI Hip 72195, 72196, 72197, 73721, 73722, 73723

74150 CT Abdomen 74150, 74160, 74170

74176 CT Abdomen and Pelvis Combination 74176, 74177, 7417878813 PET Scan 78811, 78812, 78813, 78814, 78815, 78816

78451 Myocardial Perfusion Imaging – Nuclear Cardiology Study

78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481, 78483, 78499

0501T Fractional Flow Reserve CT 0501T, 0502T, 0503T, 0504T

Magellan Healthcare will begin their clinical records review process for Capital BlueCross on August 1. The following imaging tests will require clinical record documentation:

The CVR Process

• At the end of an authorization request, the request will pend for additional clinical information. The provider will be asked to submit certain aspects of the record for review prior to an authorization request from Magellan Healthcare.

• Magellan Healthcare will immediately reach out to the plan-ordering provider’s office to request needed clinical information from the patient’s medical record.

• When requested, validation of clinical criteria within the patient’s medical record is required before an approval can be made.

• Magellan Healthcare will validate the clinical criteria within the patient’s medical record, ensuring that clinical criteria that support the requested test are clearly documented.

• This helps ensure that patients receive the most appropriate and effective care.

11

• Guidelines are reviewed and mutually approved by Capital BlueCross and Magellan Healthcare’s Chief Medical Officers.

• Magellan Healthcare’s algorithms and medical necessity reviews collect key clinical information to ensure that Capital BlueCross members are receiving appropriate care prior to more invasive procedures. Our goal: ensure that Capital BlueCross members are receiving the appropriate level of care.

• Clinical Guidelines are available on www.RadMD.com

Clinical Decision Making and Algorithms

12

Patient and Clinical Information Required for Authorization

GENERAL

Includes things like ordering physician information, member information, rendering provider information, requested examination, etc.

CLINICAL INFORMATION

• Includes clinical information that will justify examination, symptoms and their duration, and physical exam findings

• Preliminary procedures already completed (e.g., X-rays, CTs, lab work, ultrasound reports, scoped procedures, referrals to specialist, and specialist evaluation)

• Reason the study is being requested (e.g., further evaluation and rule out a disorder)

Refer to the Prior Authorization Checklists on RadMD for more specific information.

13

Magellan Healthcare to Ordering Provider: Request for Additional Clinical Information

• A fax and fax coversheet is sent to the provider detailing what clinical information is needed

• 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 noncertification

14

Submitting Additional Clinical Information/Medical Records to Magellan Healthcare

• There are two ways to submit clinical information to Magellan Healthcare

—Fax

—RadMD upload

• Use the fax coversheet when faxing clinical information to Magellan Healthcare

• Additional copies of fax coversheets can be printed from RadMDor requested from the call center at 888.203.1423

Be sure to use the Magellan Healthcare fax coversheet for all clinical information transmissions!

15

CVR Process for Ordering Providers

Algorithm questions

asked

System customizes next steps based on provider profile

and program selected

Records Not Required

Request Approvable

Request Approved

Request NOT approvable

Records required2

(targeted CVR studies)

Specific fax sent to

provider with clinical info

needed

Provider records

support clinical necessity

Request approved

Provider records do

not support clinical

necessity

Peer-to-peer required

Peer-to-peer required

Ordering providers requesting advanced imaging procedures

from Magellan Healthcare using CVR process

Records not required(non-CVR studies)

Request approvable

Request approved

16

Prior Authorization Process

Intake Level Initial Clinical Review

Requests are evaluated using our clinical algorithms

Requests may:• Approve• Require additional

clinical review and pend for clinical validation of medical records

• Pend for clinical validation of medical records

Nurses will review request and may:

• Approve

• Send to Magellan Healthcare physician for additional clinical review

Physicians may:

• Approve

• Deny

Physician Clinical Review

17

A peer-to-peer discussion is always available!

Provider Tools and Contact Information

Provider Tools

Toll free authorization and information number: 888.203.1423 Available 8 a.m. – 8 p.m. EST

• Interactive Voice Response (IVR) System for authorization tracking

RadMD Website available 24/7 (except during maintenance)

• Request authorization (ordering providers only) and view authorization status

• Upload additional clinical information

• View clinical guidelines, frequently asked questions (FAQs), and other educational documents

19

Ordering Provider: Getting Started on RadMD.com

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 email address so our webmaster can email you your Magellan Healthcare-approved username and password.

NOTE: On subsequent visits to the site, click the Sign Inbutton to proceed.

1Everyone in your organization is required to have their own separate username and password due to HIPAA regulations.

2

3

20

Offices that both order and render should request ordering provider access—this will allow your office to request authorizations on RadMD and see the status of those authorization requests.

Rendering Provider: Getting Started on RadMD.com

STEPS:

1. Click the New User button on the right side of the home page.

2. Select “Facility/office where procedures are performed.”

3. Fill out the application and click the Submit button.

You must include your email address so our Webmaster can email you your Magellan Healthcare-approved username and password.

NOTE: On subsequent visits to the site, click the Sign Inbutton to proceed.

IMPORTANT

• Everyone in your organization is required to have their own separate username and password due to HIPAA regulations.

• Designate an administrator for the facility who manages the access for the entire facility.

1

2

3

21

If you have multiple staff members entering authorizations and you want each person 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.

When to Contact Magellan Healthcare

Ordering and Rendering Providers: To initiate a request or check the status of an authorization, please contact Magellan Healthcare

through our website, www.RadMD.com, or call our toll-free number, 888.203.1423. For assistance or technical support for RadMD, please email the RadMD Help Desk at

[email protected] or call 877.80.RadMD (877.807.2363). For any provider education requests or questions specific to Magellan Healthcare and the

Medical Specialty Solutions Program, email Lori A. Fink, Provider Relations Manager, at [email protected] or call her at 800.450.7281, ext. 32621.

22

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 Capital Blue Cross 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 Capital Blue Cross and Magellan Health, Inc.

Thank you!