Questions and Answers

Transcription

1 Questions and Answers Radiation Oncology Utilization Management Program Why did Florida Blue implement a radiation oncology utilization management program? The purpose of the program is to ensure radiation therapy treatment plans are clinically appropriate for each patient s specific condition, conducted in the most efficient manner and delivered according to nationally recognized clinical guidelines. Florida Blue and Florida Blue HMO (Health Options, Inc.) retained AIM Specialty Health to manage the radiation oncology program on their behalf. Providers can request prior authorization through the AIM provider portal or by calling the AIM Specialty Health toll-free number at (844) When is the program effective? January 1, 2016, for Medicare Advantage BlueMedicare SM HMO and BlueMedicare SM PPO members May 1, 2016, for: Large group: non-grandfathered BlueOptions SM (NetworkBlue), BlueCare HMO (Health Options, Inc.), BlueChoice (Preferred Patient Care) plans Small group: Affordable Care Act BlueOptions (NetworkBlue), BlueCare HMO (Health Options, Inc.), BlueSelect (BlueSelect network) plans Individual: Affordable Care Act BlueOptions (NetworkBlue), BlueCare HMO and myblue HMO (Health Options, Inc.), BlueSelect (BlueSelect network) plans Are there any exceptions? Yes. This program will not apply to members who are covered through self-insured administrative services only (ASO) plans nor will it apply to any members of other Blue Cross and/or Blue Shield Plans that may access the above networks through the BlueCard program. Which radiation oncology services require a prior authorization? Intensity modulated radiation therapy (IMRT) including reviews for: - Image guidance (IGRT), hypo fractionation for bone metastases and breast cancer 3D conformal (EBRT) - Registration only except for bone metastases and breast cancer including reviews for Image guidance (IGRT), hypo fractionation for bone metastases and breast cancer Proton beam therapy - Stereotactic body radiation (SBRT) Stereotactic radiosurgery (SRS) Brachytherapy Associated services review for special procedures and consults (CPT codes and 77470) 1

2 Why did Florida Blue select AIM Specialty Health? AIM Specialty Health is a clinically driven program designed to effectively manage quality, patient safety and ensure appropriate utilization of resources for Florida Blue members. When is prior authorization required for radiation oncology services? For the plans listed on page one, prior authorization is required for radiation oncology procedures outside of the emergency room or inpatient setting and must be obtained before the service is performed. Note: Radiation oncology management procedures performed in the emergency room or inpatient setting do not require prior authorization. Is prior authorization required for members currently undergoing treatment? Yes. Authorization is required for dates of service on or after January 1, 2016, for the program described above for BlueMedicare HMO and BlueMedicare PPO health plans, and on or after May 1, 2016, for the other health plans listed on page one. Are inpatient radiation oncology management procedures included in this program? They are not included in this program. Does the location of service affect prior authorization requirements? Prior authorization for radiation oncology procedures is required for all locations of services other than the emergency room and inpatient including POS 11-office, POS 22-outpatient and POS 24- ambulatory surgical center. How should a provider obtain prior authorization for radiation oncology treatment services? First verify that a patient requires an authorization and who will service the authorization by using the triage process described below (see Temporary Authorization Triage Process). For authorizations that are handled by AIM, providers can request prior authorization through the AIM provider portal or by calling the AIM Specialty Health toll-free number at (844) AIM provider portal login information is provided below: 1. Go to select Register Now 2. Enter : Name Organization Address Phone Fax address 3. Username/password parameters will display. 2

3 4. Select Provider type generally ordering provider (if a physician office) or servicing provider (if a facility) 5. Enter a unique identifier, usually the TIN 6. Once the required information is submitted, providers will get a confirmation from AIM. Note: Requests are processed by AIM s Web Care Service Team. Temporary Authorization Triage Process Ordering and rendering providers are encouraged to use our authorization triage process if there is uncertainty as to whether this program applies to a patient. You can obtain a triage form on our website at floridablue.com; select Providers (top of the page), Forms and then Radiation Oncology Services Temporary Instructions and Request Form. After completing the triage form, it to our triage team at: NonDelegatedAuthorizationsMSK_SMS_RadOnc@bcbsfl.com. What information does AIM Specialty Health require to process a prior authorization? Providers should have the following information ready before logging on to the providerportal.com website or calling the AIM Specialty Health call center at (844) (* means required information): Name and office phone number of ordering physician* Member name and ID number* Requested procedure* Name of provider office or facility where the service will be performed* Anticipated date of service* Details justifying the radiation oncology procedure*: Physician exam findings and patient symptoms (including findings applicable to the requested services) Clinical diagnosis Date and results of radiation oncology UM management procedures. Treatment modalities completed, duration and results (e.g., intensity modulated radiation therapy (IMRT), proton beam therapy, brachytherapy, etc.) Please be prepared to fax the following information, if requested: Clinical notes outlining treatment modalities, outcomes and physical exam findings Date and results of prior radiation oncology UM management procedures Specialist reports/evaluation Can a provider request more than one procedure at a time for a member? Yes. All radiation oncology UM procedures require authorization from AIM Specialty Health. Requests for repeat procedures would require updated or new clinical information because the medical information may have changed. When can ordering providers expect a response for prior authorization requests? A response is usually received within two (2) business days after receipt of the request if all required clinical documentation is provided. In certain cases, the review process can take longer if additional clinical information is required to make a determination. 3

4 The best way to expedite an authorization request is online through or through the toll-free number at (844) with the following information: The patient s history and diagnosis Findings on physical examination Response and type of management the patient has undergone History of medical or surgical treatment Rationale for the procedure What does an authorization number look like? The authorization number consists of 8 or 9 alpha-numeric characters (i.e., A ). In some cases, the ordering provider may receive an AIM tracking number (not the same as an authorization number) if the provider s authorization request is not approved at the time of initial contact. Providers will be able to use either number to track the status of their request online or through AIMs interactive voice response (IVR) telephone system. What happens if an authorization request pends through provider portal? Providers will receive a tracking number and AIM will contact the provider to complete the process. Can the provider portal be used to request expedited authorization requests? No. Expedited requests must be requested telephonically by calling AIM s call center at (844) How long is a prior authorization number valid? The authorization number is valid for 90 days from the date of the request. If a provider obtains a prior authorization number, does that guarantee payment? An authorization number is not a guarantee of payment. Authorizations are based on medical necessity and are contingent upon eligibility and benefits. Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Will the AIM authorization number display on Availity 1? No. What if a provider disagrees with AIM Specialty Health s decision? If a prior authorization or claim payment is denied, providers may appeal the decision through the standard Florida Blue appeal procedures. Providers should follow the instructions on their authorization denial letter or Explanation of Payment (EOP) notification. Will AIM Specialty Health make a final determination based on the anticipated date of service? AIM Specialty Health does not guarantee final determination of a request by the anticipated date of service. 4

5 AIM Specialty Health needs two (2) business days after receipt of clinical information in order for review and to render a decision. Providers should not schedule or perform a procedure until the authorization request is approved. Which medical providers are impacted by the radiation oncology program? Providers who specialize in radiation oncology management procedures in an outpatient setting are impacted by this program. These providers generally practice at: Ambulatory surgical centers Hospital outpatient facilities Provider offices Where do providers send claims for radiation oncology services? Florida Blue network providers should continue to send claims directly to Florida Blue. Providers are encouraged to submit claims electronically through Availity 1 How can providers check claims status? Providers should continue to check claims status with Florida Blue as they do today. Who can providers contact if they wish to appeal a prior authorization or claims payment denial? Providers should follow the appeal instructions included on the authorization denial letter or Explanation of Benefits (EOB) notification. Do member ID cards include AIM Specialty Health and Florida Blue information or do members receive two ID cards? The Florida Blue member ID card will not change. It will not include AIM Specialty Health information Where can providers find Florida Blue guidelines for radiation oncology procedures? Please refer to our online medical coverage guidelines at floridablue.com; select Providers (top of the page), Tools & Resources, and then Medical Policies. What if I need more information? If you have general questions about this information, please call the Provider Contact Center at (800) or AIM Specialty Health at (844)