CareCore National Musculoskeletal Management Program Physical Medicine and Therapy Frequently Asked Questions

Transcription

1 EVIDENCE-BASED HEALTHCARE SOLUTIONS CareCore National Physical Medicine and Therapy Prepared for December 2, 2014

2 Table of Contents Introduction to CareCore National... 3 Who is CareCore National?... 3 What is the relationship between Oscar Insurance and CareCore National?... 3 How can Oscar Insurance participating providers obtain and verify a prior authorization number?... 3 What are CareCore National s hours and days of operation?... 3 What holidays does CareCore National observe?... 3 Will CareCore National be processing claims for Oscar Insurance?... 3 Will new ID cards be issued to Oscar Insurance members?... 3 Which Oscar Insurance members are included in the UM Program?... 3 Who do I call to verify member eligibility?... 3 Where do I submit claims?... 3 Does the authorization number need to be on the claim?... 4 What services are managed through the Physical Medicine and Therapy UM Program?... 4 Physical Medicine and Therapy (PT/OT/ST/CHIRO)... 4 What is a Notification?... 4 What are the Notification submission requirements?... 4 What is a Treatment Request?... 4 What are the pre-authorization requirements for the UM Program?... 4 Will pre-authorizations specify the number of services/units approved?... 4 When I submit a Notification, will I know if a Treatment Request is also required?... 4 What is an Approved Time Period?... 4 Why are Approved Time Periods limited to 30 days?... 5 Can I use my own forms when requesting authorization?... 5 What do I enter as the "Start Date" on my Notifications or Treatment Requests?... 5 How far in advance can I submit a Treatment Request?... 5 Can I include Durable Medical Equipment (DME) supplies on an authorization request to CareCore?... 5 What is the timeframe for a case to go through the Treatment Request review process?... 5 Will clinical reviews be done by a practitioner of the same discipline?... 5 Is peer-to-peer consultation available?... 6 How can I track the status of my Treatment Requests?... 6 Can I request more treatment after my Approved Time Period expires?... 6 Can I extend the End Date of an authorization if I didn't use all the approved visits?... 6 Can I file an appeal for cases that have been denied or partially denied?... 6 Are the clinical criteria available for review?... 6 Will separate authorizations be required for a patient with two concurrent diagnoses?... 6 If a member goes to a new practitioner for services, will a new Notification be required?... 6 If a primary care provider (PCP) refers a patient, will that make any difference in the approval?... 6 Interventional Pain Management... 6 What procedures will require prior authorizations?... 7 What information will be required to obtain a prior authorization?... 7 Do the services provided in an inpatient setting at a hospital or emergency room setting require a prior authorization?... 7 What is the process that providers will follow if CareCore National is not available when they need to obtain a prior authorization?... 7 How long will the prior authorization process take?... 7 What types of physicians does CareCore National employ to review prior authorization requests?... 7 What information about the prior authorization will be visible on the CareCore National Web site?... 8 Page 2 of 8

3 How will all parties (referring provider, rendering provider, and member) be notified if the prior authorization has been approved?... 8 If a prior authorization is not approved, what follow up information will the referring provider receive?... 8 Is there is an appeals process if the prior authorization is not approved?... 8 What is the format of the CareCore National authorization number?... 8 Is a separate authorization needed for each CPT code?... 8 How long will the authorization approval be valid?... 8 If a prior authorization number is valid for 45 days and a patient comes back within that time for follow up and needs another procedure, will a new authorization number be required?... 8 Introduction to CareCore National Who is CareCore National? CareCore National provides Utilization Management services for Health Plans. What is the relationship between Oscar Insurance and CareCore National? Oscar has contracted with CareCore since January 2014 to manage diagnostic imaging, medical oncology, cardiology, and MSM/Pain services. Starting in January 2015, Oscar has contracted with CareCore National to manage Diagnostic Sleep Testing and Sleep Therapy Services at participating sites. How can Oscar Insurance participating providers obtain and verify a prior authorization number? You can submit authorization requests online at or via phone at What are CareCore National s hours and days of operation? CareCore National is available from 7:00 a.m. to 7:00 p.m. EST Monday through Friday. What holidays does CareCore National observe? New Year s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and the Friday following, and Christmas Day. Will CareCore National be processing claims for Oscar Insurance? No. Will new ID cards be issued to Oscar Insurance members? No. Which Oscar Insurance members are included in the UM Program? All. Who do I call to verify member eligibility? Follow your normal Oscar Insurance process for eligibility verification. For more information please check hioscar.com/provider. Where do I submit claims? Follow your normal Oscar Insurance process for claims submission. For more information please check hioscar.com/provider. Page 3 of 8

4 Does the authorization number need to be on the claim? No. There are no changes for submitting a claim. Follow the standard Oscar Insurance claims filing process. What services are managed through the Physical Medicine and Therapy UM Program? The Physical Medicine and Therapy UM Program manages outpatient services for: Physical Therapy/Occupational Therapy Speech Therapy Chiropractic Care Interventional Pain Management Physical Medicine and Therapy (PT/OT/ST/CHIRO) What is a Notification? A Notification is the required information submitted to CareCore informing Oscar Insurance that a member is starting care. This Notification consists mostly of patient demographic information. The Notification allows for claims payment; the number of visits payable varies based on each request. What are the Notification submission requirements? All physical medicine/therapy practitioners must submit a Notification within seven (7) days of the initial evaluation. You may also need to submit a Treatment Request to obtain pre-authorization for the treatment episode. The Notification or a Treatment Request may be submitted by the servicing practitioner or his/her office staff. The preferred method to submit the Notification information is online at Online submissions are available 24/7. Notifications can also be submitted by phone at between 7 a.m. and 7 p.m. EST Monday through Friday. What is a Treatment Request? The Treatment Request is a tool required for submission of patient and practitioner information for medical necessity review. Treatment Requests are condition-specific based on the type of service requested. The preferred method to submit Treatment Requests is online at With online submission, you may receive an instantaneous review determination for your Treatment Request. You may also call CareCore at , 7 a.m. through 7 p.m. local time Monday through Friday. What are the pre-authorization requirements for the UM Program? If you are an Oscar Insurance participating-practitioner, you may be required to submit a Treatment Request to obtain pre-authorization for all treatment after the initial visit. Will pre-authorizations specify the number of services/units approved? Yes. When visits are authorized based on a Notification or Treatment Request, the authorization will provide the number of approved services for those visits. When I submit a Notification, will I know if a Treatment Request is also required? Yes. After your initial submission, CareCore will prompt you to complete a Treatment Request if one is required at the time you submit your Notification. What is an Approved Time Period? Page 4 of 8

5 The Approved Time Period is the time period (duration) available to use approved visits. Visits and units must be spread throughout the authorized period to avoid a gap in care at the end of the Approved Time Period. Why are Approved Time Periods limited to 30 days? Medical necessity authorizations are typically approved for a 30-day period, allowing the servicing practitioner to assess the patient s response to treatment. Can I use my own forms when requesting authorization? No. To ensure that clinical peer reviewers receive necessary and complete information, and to make consistent clinical determinations, the Treatment Request is required for medical necessity reviews. What do I enter as the "Start Date" on my Notifications or Treatment Requests? For Non-Chiropractic initial Notifications, the Start Date is the patient's initial evaluation date. Under the UM program, your first Treatment Request Start Date will be the seventh visit if you received an initial authorization for six "waiver" visits when you submitted your Notification. For continuing care requests, the Start Date is the first visit that requires pre-authorization after the previous Approved Time Period expiration. Do not enter the first date of the patient's treatment episode for continuing care requests. For Chiropractic care requests beyond 10 visitis, the first Treatment Request Start Date will be the date of the eleventh visit. Do not enter the first date of the patient's treatment episode for continuing care requests. How far in advance can I submit a Treatment Request? Submit Treatment Requests no more than seven (7) days prior to the proposed Start Date. Requesting care too far in advance does not allow you to report up-to-date examination findings. The objective findings date reported on your Treatment Request should be within seven (7) days of your requested Start Date. To avoid a delay in receiving a review determination, provide current clinical findings, paying particular attention to how you document the patient s progress with the services you have already provided. Can I include Durable Medical Equipment (DME) supplies on an authorization request to CareCore? You may document that a patient requires specialized DME equipment; however, orthotics, DME, and supplies will not be authorized by CareCore. Follow the normal Oscar Insurance process for all DME. For more information please check hioscar.com/provider. What is the timeframe for a case to go through the Treatment Request review process? If medical necessity can be established based on evidence-based criteria, visits will be pre-authorized at the time of your Treatment Request submission. When you submit online, this preauthorization will be instantaneous. When a clinician review is required, CareCore's review determination timeframes will comply with applicable regulations. The turnaround times are dependent upon all necessary information being provided to CareCore. If there is insufficient information to make a determination, CareCore will fax you a hold letter indicating the information that is still required. The surest way to avoid this scenario is to have updated clinical information available before contacting CareCore. Will clinical reviews be done by a practitioner of the same discipline? Page 5 of 8

6 Yes. Requests requiring clinical evaluation will be reviewed by appropriate specialty clinicians. For example, chiropractors review Treatment Requests for chiropractic services. All adverse determinations for therapy services are physician reviewed. Is peer-to-peer consultation available? Yes. When there is a request for a peer-to-peer conversation, CareCore makes an effort to immediately transfer the call to an available CareCore clinical reviewer. When one is not available, a scheduled call-back is offered at a time that is convenient for your practice. These timeframes will comply with applicable regulation and law. How can I track the status of my Treatment Requests? To check the status of a case, log on to and select Authorization Lookup. Can I request more treatment after my Approved Time Period expires? Yes. If you believe a patient will require more visits after the Approved Time Period expires, submit an updated Treatment Request for continuing care. Keep in mind that Treatment Request periods cannot overlap. Therefore, be sure the Start Date of your request for continuing care is after the expiration of your previous authorization. Can I extend the End Date of an authorization if I didn't use all the approved visits? Yes. CareCore will approve one extension per Approved Time Period up to 30 days. Can I file an appeal for cases that have been denied or partially denied? We recommend that you utilize the reconsideration process before filing a formal appeal. Reconsiderations are completed via the telephone and through peer-to-peer consultations as applicable. If the initial decision is upheld, then the next step is a first-level appeal. The review determination letter will provide instructions for appealing a medical necessity decision, including your right to submit additional information. Are the clinical criteria available for review? Yes. Evidence-based criteria will be available online through the CareCore National practitioner web portal at Will separate authorizations be required for a patient with two concurrent diagnoses? No. Each medical necessity review considers all reported diagnoses for the patient. However, separate Notifications and Treatment Requests are required for patients receiving care from multiple practitioners or specialties (e.g., for a patient receiving both physical therapy and acupuncture therapy). If a member goes to a new practitioner for services, will a new Notification be required? Yes. When a member changes to a treating practitioner who is not within the same practice, a new Notification submission is required. The Treatment Request requirement for medical necessity review will be based on the new treating practitioner's UM Program assignment. If a primary care provider (PCP) refers a patient, will that make any difference in the approval? No. There are no changes in requirements for Oscar Insurance members in regards to physician referrals. Authorizations are based on medical necessity and evidence-based criteria. Interventional Pain Management Page 6 of 8

7 What procedures will require prior authorizations? Interventional Pain Procedures: Injections (Epidurals, Facet Joint, Sacroiliac Joint, Peripheral Nerve, Trigger Point, Ganglion); Nerve Blocks/Ablations, Epidural Catheters, Pain Pumps, Spinal Cord Stimulators; and associated anesthesia and radiology procedures. A complete list of CPT codes that require prior authorization can be found on the CareCore National website at If a Primary Care Physician refers a patient to a specialist, who determines that the patient needs a study that requires prior authorization, who needs to request the prior authorization? The physician who orders the study should request the prior authorization. In this case, it would be the specialist. What information will be required to obtain a prior authorization? Member s Plan Name Patient s Name, Date of Birth, and Member ID Number Ordering Physician s Name, Provider ID Number, Address, Telephone and Fax Numbers Facility s Name, Telephone and Fax Number Clinical Information Clinical Diagnosis Past Medical History Signs and Symptoms Physical Exam Findings Results of Relevant Tests Relevant Medications If initiating the prior authorization by telephone, the caller should have the medical record available. Please note that some procedures may require clinical notes to be submitted to CareCore National prior to an authorization being issued. Do the services provided in an inpatient setting at a hospital or emergency room setting require a prior authorization? Studies ordered through an emergency room treatment visit or during an inpatient stay do not require a prior authorization. What is the process that providers will follow if CareCore National is not available when they need to obtain a prior authorization? Providers may submit a request up to three (3) days after the service has been rendered via the web and CareCore National will process on the next business day. The clinical indication for the test must be included. How long will the prior authorization process take? 70% of all requests reach a final determination on first contact. If a prior authorization is initiated online and the request meets criteria, the test will be approved immediately, a time stamped approval will be available for printing. What types of physicians does CareCore National employ to review prior authorization requests? CareCore National employs physicians of various specialties to respond to network needs. The physicians employed have expertise in those procedures covered by the program to review clinical cases and to be available for physician to physician calls as necessary. Page 7 of 8

8 What information about the prior authorization will be visible on the CareCore National Web site? The authorization status function on the Web site will provide the following information: Prior Authorization Number/Case Number Status of Request CPT Code(s) and quantities of the code(s) Procedure(s) Name Site Name and Location Prior Authorization Date Expiration Date How will all parties (referring provider, rendering provider, and member) be notified if the prior authorization has been approved? Referring providers will be notified of the prior authorization via fax. Rendering providers can validate a prior authorization by using the CareCore National website. Members will be notified in writing of any adverse determinations. Written notification is provided upon request if the rendering provider contacts CareCore National s Customer Service. If a prior authorization is not approved, what follow up information will the referring provider receive? The referring provider will be informed of the reason for denial, as well as how to initiate a reconsideration or appeal. If a provider resubmits an authorization request for a service within the timeframe allowed for an appeal that was previously denied, CareCore National will consider this request an appeal. If the timeframe to file an appeal has expired, the request will be treated as a new request for authorization. Within fourteen (14) business days after the denial has been issued, the provider may request reconsideration with a CareCore National Medical Director to review the decision. Is there is an appeals process if the prior authorization is not approved? Yes. Appeal rights are detailed in communications sent to the providers with each adverse determination. Providers may also request reconsideration from CareCore within fourteen days of the denial decision. What is the format of the CareCore National authorization number? An authorization number is (1) one Alpha character followed by (9) nine numeric numbers. For example: A Is a separate authorization needed for each CPT code? Yes. Each individual CPT code will require an authorization. How long will the authorization approval be valid? Prior Authorizations are valid for 45 calendar days from the date of the approval. If a prior authorization number is valid for 45 days and a patient comes back within that time for follow up and needs another procedure, will a new authorization number be required? Yes. Page 8 of 8