Provider Refresher Training Program 2011. Provider Training Program Agenda Welcome and Opening Remarks Program Components Facility Selection Support Program.

Provider Refresher Training Program2011

Provider Training Program Agenda

• Welcome and Opening Remarks• Program Components• Facility Selection Support Program• How the Program Works:

• Authorization Process

• Algorithms Guidelines

• Radiation Awareness• Provider Self-Service Tools (RadMD and IVR)• NIA Provider Relations and Contact Information• Questions and Answers

NIA—A Magellan Health Company 2

Program Components• Utilization Management/Authorizations: NIA's proprietary, evidence-based

decision algorithms support scripting for call center representatives or online, leading to quick procedure approval or consultation with our radiology experts.

• Information and Transaction Tools: Our online resource, www.RadMD.com, gives ordering providers the ability to request and obtain authorizations, reference lists of nearby imaging facilities, locate authorizations and submit rapid authorization requests. Providers report a high level of satisfaction with their use of RadMD, finding it a simple tool to use and a time-saver for staff.

• Ordering Provider Program: Analyze referral patterns with the Health Plan and develop additional education and outreach opportunities to the provider community to review various facility options based upon convenience factors for members (i.e., free parking, on a public transportation line, weekend hours, etc.)

• Provider Privileging: The program includes privileging of the Health Plan’s freestanding facilities and the Health Plan’s in-office providers for advanced and cardiac imaging. The program promotes continuous quality improvement, provides scope of practice limitations and enables consumers to make educated health care decisions. Hospitals are excluded from the privileging program.


http://www.radmd.com/

Facility Selection Support Program

Facility Selection Support Goals

The facility selection process is based on patient support and cost effectiveness

• Primary consideration is always the clinical aspect of the patient when making facility recommendations.

• Helps ensure that patients go to quality imaging facilities that are conveniently located.

• Supports the education of both the provider and patient about cost-effective facility alternatives.

• Facilitates the delivery of tests at free-standing, outpatient facilities (when appropriate) to support lower costs


How Facilities are Selected

• During prior authorization, the authorization representative will help the ordering provider select a facility based on:

• Facilities meeting NIA’s quality requirements and patient’s clinical need

• Location and cost differential• Convenience items important to

patient• Prior Authorization for a high cost

facility will be confirmed with the consumer if there is no clinical justification

Facilities located in or close to required zip code. Preference

given to lower cost facilities

Facilities with requested

convenience items FacilitySelected

All facilities meeting NIA’s approved facilityrequirements for the indicated test. Facilitiesalso meet the patient’s clinical requirements


Convenience Services that can be Selected

• Transportation and parking• Public transportation accessibility• Free parking

• Language assistance• Languages spoken by office staff• Telecommunication equipment for deaf patients

• Weekend or evening hours• Extended evening hours• Weekend hours


The Authorization Process

NIA Prior Authorization is required for:Non-emergent outpatient, short stay and urgent care

• CT/CTA Scan• CCTA• MRI/MRA• PET Scan• Diagnostic Nuclear Medicine• Nuclear Cardiology/MPI• Echocardiography• Stress Echo

• Any code specifically cited in the Health Plan/NIA Billable CPT® Code Claims Resolution Matrix.

• All other procedures will be adjudicated and paid by the Health Plan per their guidelines.

• Authorizations are valid for sixty (60) days from date of initial request.


NIA Prior Authorization is not required for:

• Inpatient, Observation or Emergency Room:

• CT/CTA

• CCTA

• MRI/MRA

• PET Scan

• Diagnostic Nuclear Medicine

• Nuclear Cardiology/MPI

• Echocardiography

• Stress Echo


Physicians’ office contacts NIA for prior authorization of study

RA

DM

D.C

OM

Te

lep

ho

ne

Clinical information complete – procedure

approved

Clinical information not complete –

additional information needed

System evaluates request based on physician entered

information

Request for specific clinical

information needed

Additional clinical information complete

–procedure approved

Additional clinical not complete or

inconclusive

Initial Clinical Specialty Team Review

Physician Approves Case Without Peer-to-

Peer

Physician Approves Case With Peer-to-Peer

Physician DeniesCase

Physician Review

Ordering Physician Withdraws CaseW

92% of all cases receive final determinations in 24 – 48 hours.

?

?

NIA Clinical UM Authorization Process

NIA— A Magellan Health Company | 11

Algorithms/Guidelines

NIA Clinical Expertise and Provider Engagement

NIA reviews more than 450,000 advancedimaging provider requests each month.

Algorithms and guidelines are reviewedand mutually approved by Geisinger Health Plan and NIA chief medical officers.

Many NIA algorithms recommend substitutingmore costly but more effective imaging technology.Our goal–the most appropriate test early in anepisode of care for “Client” members.

Clinical consultation is a hallmark of NIA– we have 86 board-certified physicians representing radiology and a host of other specialties available for physician-to-physician (peer-to-peer) discussion.

NIA— A Magellan Health Company | 13

Access Clinical Guidelines on RadMD Home Page


This screen allows you to select:•Health Plan

•Type of Study

•Exam

Clinical Guidelines Search


From a drop down list on the NIA Clinical Guideline page, Select the appropriate

Health Plan and Study


Select the exam you want to review. A PDF document will open the guideline selected.



Lumbar Spine CTExample of Clinical Information Needed

Algorithms can recommend SubstitutingMore Costly but More

Effective Imaging Technology


Prior Authorization ChecklistInformation needed to make Medical Necessity Determination


Requests Pended for Clinical ReviewUpload Clinical Documentation or use Fax Coversheet


Radiation Awareness

Radiation Awareness Program

NIA, in partnership with the Health Plan, has implemented a Radiation Awareness Program to educate the provider community as well as the members on radiation exposure.

Goals of the Program

• Inform ordering providers of past exposure

• Offer provider education and consultation


Radiation Awareness Program

Distinguishing Features

• Claims-based, member-specific radiation accumulator

• NIA will advise ordering providers of patients with high level exposure

(=>50 mSv cumulatively while with the Health Plan) to radiation during authorization requests and offer peer-to-peer consultation.

• Provider/member educational content is available

• Medical necessity decisions are not impacted by the patient’s radiation exposure - information is intended to assist the provider with the member’s care.

More information on radiation awareness is available on our website, www.RadMD.com.



Radiation Awareness


Radiation Exposure Adds Up Over Time


Self Service Tools and Usage

Self Service Tools and Usage

• Interactive Voice Response (IVR)

• Use tracking number to check status of cases

• Web site: www.RadMD.com

• Use tracking number to review an exam request



NIA Web Site www.RadMD.com

The NIA web site gives providers access to:

• Information concerning approved authorizations. Go to www.RadMD.com and login with username and password.

• Search the site using the patient’s ID number, name or authorization number.



Initiate an Authorization Request on RadMD


Available Sunday-Friday, 5:00 a.m. to 12:00 am Saturday 8:00 a.m. to 1:00 p.m. EST

Imaging FacilitiesView all Requests Entered by Ordering

Provider


Search Authorization by Name, Member ID Number or view All Requests


NIA RadMD Website

User-friendly, near-real-time Internet tool offered by NIAo Sign in at www.RadMD.com

RadMD website offers access to: o Member preauthorization'so Date initiatedo Exam requestedo Valid billing codes (CPT)

Helpful resources including: o Evidence-based Clinical Guidelines (by diagnosis)o Outpatient Radiology Billable CPT® Codes Claim Resolution Matrix o Radiology Utilization Management Quick Reference Guideo NIA Frequently Asked Questions (FAQs)


Magellan Health Services, Inc. | 34

• Login and click the new user button on the right side of the home page.

• 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 username and password.

• HIPAA regulations require everyone in your organization to have his or her own username and password.

• On subsequent visits to the site, click the login button to proceed.

To get started, visit www.RadMD.com

RadMD Demonstration

NIA Provider Relations

NIA Contact Information

• NIA Provider Relations Manager

• Charmaine Gaymon

• Phone: (410) 953-2615

• Email: [email protected]

• Provides educational tools to ordering and rendering providers on imaging processes and procedures.

• Liaison between Geisinger Health Plan Provider Relations and NIA.


mailto:[email protected]

Questions and Answers

Provider Refresher Training Program 2011. Provider Training Program Agenda Welcome and Opening Remarks Program Components Facility Selection Support Program.

Documents

ordering provider program

privileging program

provider privileging

patient support

high cost facility

quality imaging facilities

program works

provider community