EVIDENCE-BASED HEALTHCARE SOLUTIONS. CareCore National. Prepared for. Prepared for. October 23, 2009

Transcription

1 EVIDENCE-BASED HEALTHCARE SOLUTIONS CareCore National Medical CARECORE Oncology NATIONAL Program RADIOLOGY Frequently BENEFIT Asked MANAGEMENT Questions PROPOSAL Prepared for Prepared for October 23, 2009 December 19, 2013

2 Oscar Insurance CareCore FAQs Q: Who is CareCore National? A: CareCore National is a company that provides Utilization Management services for Health Plans. CareCore National s mission is to provide Outpatient Diagnostic Cardiology Service programs that improve quality and appropriateness of service. Q: What is the Oscar Insurance Specialty Drug Prior Authorization program? A: The Oscar Insurance Specialty Drug Prior Authorization program is a prior authorization process required for Oscar Insurance-participating physicians, health care professionals, facilities and ancillary providers for certain specialty drugs, prior to performance, with administrative claim denial for noncompliance and clinical claim denial for lack of medical necessity. Services that take place in an emergency room (ER), observation unit, urgent care center or during an inpatient stay do not require prior authorization. Please note that for Oscar Insurance, only select specialty drugs will require prior authorization. For a complete list of specialty drugs that require prior authorization, please visit OscarOnline.com > Clinical Resources > Specialty Drugs. Failure to complete the specialty drug prior authorization protocol may result in an administrative denial for non compliance and/or clinical claim denial for lack of medical necessity. Claims denied for failure to request prior authorization may not be balance-billed to the patient. Failure to meet clinical criteria will result in a denial for lack of medical necessity because services that are not medically necessary are not covered under Oscar Insurance. Upon issuance of the denial for lack of medical necessity, the member and provider will receive a denial notice with the appeal process outlined. Q: Why are Oscar Insurance-participating physicians required to utilize the Oscar Insurance Specialty Drug Prior Authorization Program? A: There has been a rapid expansion in the availability and cost of specialty drugs relevant to oncology practice. It is also widely appreciated that significant variations can occur in the use of these drugs as evidence by observations such as a New England Journal of Medicine article by Yuting Zhang, Katherine Baicker, and Joseph P. Newhouse5, which found that the quality of prescribing for the elderly varies substantially among local markets substantially more, in fact, than does spending on drugs overall. Their results showed an association between lower quality prescription patterns and more adverse drug events that may require additional expense to treat. Similarly, analysis of Oscar Insurance data shows variation in how chemotherapeutic agents are used as first line therapy, second line therapy, monotherapy, or in combination. Particularly for the less common and difficult to treatment cancers, the substantial variation did not correlate well with improved quality of life or increased survival. This program will support optimal evidenced-based use of these important therapeutic agents. Q: What are the specialty drugs that are associated with this Prior Authorization Program? A: Generic Name Brand Name Generic Name Azacitidine Bevacizumab Bortezomib Cetuximab Denosumab Doxorubicin HCl Lipid Gemcitabine HCl Immune Globulin, Intravenous (Lyphilized) Immune Globulin, Intravenous (NonLyophilized) Brand Name Vidaza Avastin Velcade Erbitux Xgeva Doxil, Caelyz Gemzar Carimune NF, Panglobulin NF and Gammagard SD Flebogamma, Gammagard, Gammaplex, Gamunex, Octagam, Privigen Page 2 of 6

3 Ipilimumab Paclitaxel Protein-bound Panitumumab Pemetrexed Rituximab Sipuleucel -T Trastuzumab Topotecan Yervoy Abraxane Vectibix Alimta Rituxan Provenge Herceptin Hycamtin Q: Is prior authorization required for ophthalmic uses of Avastin? A: No, prior authorization is only required when Avastin is prescribed as cancer chemotherapy. Q: When and how can Oscar Insurance participating providers obtain and verify a prior authorization number? A: Online at OR By calling calling CareCore National at Q: Does this program change where physicians submit claims? A: This Requirement will not change where physicians currently submit their claims. Q: What Oscar Insurance plans/ lines of business are covered under this agreement? A: All. Q: Which medical providers will be affected by this requirement? A: All physicians who perform pre-selected specialty drug injection/infusion procedures are required to obtain a prior authorization for services prior to the service being rendered in an office or outpatient setting. Physicians and facilities who render specialty drug injection/infusion procedures within the scope of this protocol must confirm that prior authorization has been obtained, or payment for their services may be denied. Q: Does an inpatient setting at a hospital or emergency room setting require a prior authorization? A: No. Services that take place through an ER treatment visit, while in an observation unit, when performed at an urgent care facility or during an inpatient stay do not require a prior authorization. For claims to be processed correctly, the place of service must indicate an inpatient, emergency room, observation or urgent care setting. Q: If a primary care physician refers a patient to a specialist, who determines that the patient needs a specialty drug that requires prior authorization, who is responsible to request the prior authorization? A: The ordering physician s office requesting the specialty drug is responsible for obtaining a prior authorization number prior to any rendering of the specialty drug. In this scenario, the specialist would be responsible for obtaining the prior authorization. Q: What Information will be required to obtain a prior authorization? A: o Member s plan name o Member s name, date of birth and member ID number o Physician s name, physician s tax ID number, address, telephone, and fax numbers o Facility / physician s name and address o Requested test(s) ( J code or description) o Working diagnosis Signs and symptoms Results of relevant tests Page 3 of 6

4 Relevant medications Working diagnosis, stage, and previous therapy If initiating the prior authorization by telephone, the caller should have the member s medical record available. Q: Are the web-based questions the same as the phone-based questions in the Specialty Drug Prior Authorization process? A: Yes, the questions are the same in both the web and phone- based Specialty Drug Prior Authorization process. Q: Who will be reviewing prior authorization requests? A: Nurses of various specialties, including oncology and home infusion, will be reviewing prior authorization requests. Medical oncologists are available as needed for peer-to-peer reviews and a medical oncologist will review all cases prior to any denial for lack of medical necessity. Q: Is a prior authorization number needed for each specialty drug ordered? A: Yes, a prior authorization number is required for each individual drug that is on the Specialty Drug Prior Authorization list. Each prior authorization number is drug-specific. Q: Does the prior authorization number need to be included on the claim form when submitting an insurance claim for payment? A: No, we do not require that you include the prior authorization number on the claim. This program does not change how you should submit claims for Medicare Advantage members. Q: How long is a prior authorization number valid? A: The length of time for which a prior authorization will be valid will vary by request. For all specialty drugs used in the palliative setting, the prior authorization will be valid for 90 days from the date the prior authorization is approved. For all specialty drugs used in the curative and adjuvant setting, the prior authorization number is valid for the number of days required to complete the requested course of treatment. This is calculated by multiplying the number of cycles requested by the length of each cycle and adding 14 calendar days. The resulting expiration date for the prior authorization will be provided to the ordering physician/provider. When a prior authorization number is approved for a specialty drug, the day the prior authorization was approved will be the starting point for the period in which the course of treatment must be completed. If the course of treatment is not completed within the approved time period, a new prior authorization number must be obtained. Q: If a prior authorization number is still active and a patient comes back within the time for follow up and needs an additional infusion of the authorized drug, will a new prior authorization number be required? A: No. If the infusion is needed during the timeframe in the prior authorization, the prior authorization will cover additional infusion services of the authorized drug. Q: How can a physician indicate that a specialty drug is clinically urgent? A: Please remember that prior authorization is not required for specialty drugs provided in an inpatient, ER, observation, or urgent care clinic setting. For in scope services rendered in other settings, a physician or other health care professional may request a prior authorization on an urgent or expedited basis in cases where there is a medical need to provide the service sooner than the conventional prior authorization process would accommodate. A prior authorization number will be issued for urgent requests within three hours of our receiving all required information. Urgent requests should be requested by phone at The physician must state that the case is clinically urgent and explain the clinical urgency to the clinical decision support representative. Page 4 of 6

5 Q: What if there is an urgent request that is scheduled after hours or on a weekend? A: Please remember that prior authorization is not required for drugs provided in an inpatient, ER, observation, or urgent care clinic setting. Retrospective authorization requests must be made within two business days of the service. Q: What if there is a clinically urgent request? A: For outpatient requests, cases initiated during normal business hours that are confirmed as clinically urgent will be decided within three hours of case initiation. Additionally, it is very important that physicians and physician staff enter all information required in order to expeditiously authorize a request. Q: How will physicians know that a prior authorization has been completed? A: Physicians will be notified of the prior authorization by fax. The physician may also verify if a prior authorization request was approved by checking the status online at or by calling The prior authorization number will be available for online verification 30 minutes after the number is issued. Written prior authorization is provided upon request to physicians by calling Q: What will happen if the physician s office does not know the specialty drug that needs to be ordered? A: Call center representatives will assist the physician s office in identifying the appropriate specialty drug based on presented clinical information. Q: Are any drug modifications allowed under the Specialty Drug Prior Authorization program? A: Based upon the J Code Crosswalk Table, for certain specified code combinations, physicians and other health care professionals will not be required to contact the Specialty Drug Prior Authorization program to modify the existing prior authorization record. A complete listing of codes is available at > Clinician Resources > Specialty Drugs: Reference Materials. Q: What is the process to modify a prior authorization where either the J Code authorized is not present on the J Code Crosswalk Table, and/or it doesn t match the drug that is needed? A: If an additional drug is needed the physician must obtain a new prior authorization number by calling This must be done within two business days of the drug being rendered. Q: If a prior authorization is not approved, what follow up information will the physician receive? A: The physician and member will be informed in writing of the reason for the denial, including the clinical rationale, as well as how to initiate an appeal. Q: Is there an appeal process if the prior authorization is not approved? A: Yes. Appeal rights are detailed in communications sent to the providers with each adverse determination. All appeals will be managed by Oscar Insurance. An authorized representative, including a provider, acting on behalf of a member, with the member s written consent, may file an appeal on behalf of a member. Q: Does receipt of a prior authorization number guarantee that Oscar Insurance will pay the claim? A: No, receipt of a prior authorization number does not guarantee or authorize payment. Payment of the covered services is contingent upon the member being eligible for services on the date of service, the provider being eligible for payment, and any claim processing requirements. Q: For members already receiving treatment when the prior authorization is required, are they required to obtain a prior authorization? A: For members that will have started but not completed treatment with one of the listed drugs when prior authorization is required, these treatments will need to be registered. Failure to register may result in an administrative claim denial. Q: How do I register the member and their current treatment? Page 5 of 6

6 A: To register the member and their current treatment, physicians will need to call Q: What information will be required to register the member and their current treatment? A: Member s plan name Member s name, date of birth and member ID number Ordering Physician s name, physician s tax ID number, address, telephone, and fax numbers Rendering facility / physician s name and address (if different) ICD-9 code Cancer classification Treatment start date Once registered, you will receive approval to complete the current course of treatment with an expiration date. Please remember that any continuation of this treatment beyond the expiration date or a change in treatment will require a prior authorization. Q: How were the evidence-based guidelines developed that are used with the Specialty Drug Prior Authorization Program? A: For Oscar Insurance, we follow Medicare s Local and National Coverage Determination policies where applicable and National Comprehensive Cancer Network (NCCN) Compendium. Q: Who creates the policies that you are adding? A: The policies are issued by the Centers for Medicare & Medicaid Services (CMS), fiscal intermediaries, Medicare administrative contractors (MACs) and carriers. The policies will be updated on a continual basis as changes are made by those entities. Q: How does the Specialty Drug Prior Authorization Program for Oscar Insurance compare with other Oscar products? A: The specialty drug program supporting Oscar Insurance is a prior authorization program that includes a medical necessity determination for the requested specialty drug. Coverage for specialty drugs that are not medically necessary will be denied as not covered under the member s benefit plan because services that are not medically necessary are not covered under Oscar Insurance plans. Failure to comply with any prior authorization protocol may result in an administrative claim denial. Q: If a denial occurs because of a coding mistake can I resubmit the claim? A: Yes, if the mistake is administrative (related to coding) then a claim can be resubmitted as long as prior authorization remains in effect and the procedure on the claim is medically necessary. Page 6 of 6