HealthPlus Amerigroup Provider Training Program

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1 HealthPlus Amerigroup Provider Training Program

2 Provider Training Program Agenda Welcome and Opening Remarks About NIA The Provider Partnership The Program Components How the Program Works: The Authorization Process o The Authorization Appeals Process The Claims Process o The Claims Appeals Process Provider Self-Service Tools (RadMD and IVR) RadMD Demo NIA Provider Relations and Contact Information Questions and Answers NIA A Magellan Health Company 2

3 National Imaging Associates (NIA)

4 About NIA NIA is accredited by NCQA and is URAC-certified National Imaging Associates (NIA) chosen as the solution for national and regional health plans covering more than 17 million lives due to: o o Distinctive clinical focus NCQA accreditation and URAC certification o Innovation and stability from parent company, Magellan Health Services, which: Enhances operational competencies, IT capabilities and patient support tools Affords financial stability for growth and continued investment in innovative technology Focus/results: Maximizing diagnostic services value and promoting patient safety through: o A clinically driven process that safeguards appropriate diagnostic treatment for HealthPlus Amerigroup members NIA A Magellan Health Company 4

5 The NIA Partnership Model Dedication to provider service and convenience o o o o o Dedicated provider relations staff Authorization call center Interactive Voice Response (IVR) Education and training programming Ongoing outreach to providers NIA A Magellan Health Company 5

6 Outpatient Imaging Program Components Prior Authorization/ Utilization Management NIA's proprietary, evidence-based decision support 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 website, RadMD.com, provides the ability for ordering providers to request and obtain authorizations, reference lists of nearby imaging facilities, locate authorizations given, and gain 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. NIA A Magellan Health Company 6

7 The Authorization Process

8 NIA Prior Authorization is required for: Nonemergent outpatient: o CT /CTA o MRI/MRA o PET scans o Nuclear cardiology Any code specifically cited in the HealthPlus Amerigroup/NIA Billable CPT Codes Claims Resolution Matrix handout The CPT Claims Resolution Matrix is available on All other procedures will be authorized and paid by HealthPlus Amerigroup per their payment policy. NIA A Magellan Health Company 8

9 NIA Prior Authorization is not required for: Emergency room, urgent care centers, inpatient and observation: o CT /CTA o MRI/MRA o PET scans o Nuclear cardiology NIA A Magellan Health Company 9

10 NIA Clinical Expertise and Provider Engagement NIA reviews more than 450,000 advanced imaging provider requests each month. Algorithms and guidelines are reviewed and mutually approved by the HealthPlus Amerigroup and NIA Chief Medical Officers. Many NIA algorithms recommend substituting more costly but more effective imaging technology. Our goal the most appropriate test early in an episode of care for HealthPlus Amerigroup 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 10

11 NIA Clinical UM Authorization Process Physicians office contacts NIA for prior authorization of study System evaluates request based on physician entered information Nurse/Clinical Specialty Team Review Physician Review Clinical information complete procedure approved Additional clinical information complete procedure approved Physician approves case without peer-to-peer? Clinical information not complete additional information needed Request for specific clinical information needed? Additional clinical not complete or inconclusive W Physician approves case with peer-to-peer Ordering physician withdraws case Physician denies case 92% of all cases receive final determinations in hours. NIA A Magellan Health Company 11

12 NIA Authorization Process The ordering physician is responsible for obtaining prior authorization. The rendering provider must ensure prior authorization has been obtained, and it is recommended that you not schedule procedures without prior authorization. Procedures performed without proper authorization will not be reimbursed. If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed, please contact NIA immediately with the appropriate clinical information for an expedited review. The number to call to obtain a prior authorization is If an emergency clinical situation exists outside of a hospital emergency room, please contact NIA immediately with the appropriate clinical information for an expedited review. The number to call to obtain a prior authorization is Separate prior authorization numbers are not needed for CT-guided biopsy, CT-guided radiation therapy and some MR-guided procedures. NIA A Magellan Health Company 12

13 NIA OCR Fax Cover Sheet Submission of Clinical Information NIA does not accept faxes for initial authorization requests. NIA utilizes OCR technology which allows us to attach the clinical information that providers send to be automatically attached to an existing prior authorization request. For the automatic attachment to occur, providers must use the NIA Fax Cover Sheet as the first page of the fax. Providers can obtain an NIA Fax Cover Sheet in the following ways: o o o If submitting a prior authorization request online through RadMD, at the end of the submission, the provider is given the option to print the cover sheet. On RadMD, click on Request a Fax Cover Sheet. This will allow the provider to print the cover sheet for a specific patient. By calling the NIA Clinical Support Department at , providers can request that a cover sheet be faxed to them. If we have sent a fax requesting additional clinical information, the NIA Fax Cover Sheet should accompany the request. Following this process will ensure a timely and efficient case review. NIA A Magellan Health Company 13

14 Requests Pended for Clinical Review Upload clinical documentation or use Fax Cover Sheet NIA A Magellan Health Company 14

15 The Authorization Appeals Process

16 The Authorization Appeals Process Appeals are processed by HealthPlus Amerigroup The ordering provider and member will receive verbal and written notification. Medical Appeals HealthPlus, an Amerigroup Company P.O. Box Virginia Beach, VA NIA A Magellan Health Company 16

17 The Claims Process

18 How Claims Should Be Submitted Rendering providers/imaging providers should continue to send their claims electronically directly to HealthPlus Amerigroup HealthPlus Amerigroup payer ID numbers: o Emdeon: o Capario (formerly MedAvant): o Availity: If unable to bill electronically, claims for HealthPlus Amerigroup members should be submitted to: HealthPlus, an Amerigroup Company P.O. Box Virginia Beach, VA NIA A Magellan Health Company 18

19 The Claims Appeals Process

20 The Claims Appeals Process In the event of a prior authorization or claims payment denial, you may appeal the decision through HealthPlus Amerigroup. o Follow the instructions on your nonauthorization letter or Explanation of Payment (EOP) notification. NIA A Magellan Health Company 20

21 Self-Service Tools and Usage

22 Multichannel Provider Relations Strategy Internet Offerings Initiate Authorization (Ordering Provider) Authorization Inquiry Interactive Voice Response IVR Interactive Voice Response Authorization Inquiry Radiology Provider Provider Relations Staff Provider Forums/Education Centralized and Regional Support NIA A Magellan Health Company 22

23 Self-Service Tools and Usage Interactive Voice Response (IVR) o Use tracking number to check status of cases Website: o Use tracking number to review an exam request NIA A Magellan Health Company 23

24 NIA Website: Information concerning approved authorizations can be viewed at after login with username and password Providers may search based on the patient s ID number, name or authorization number NIA A Magellan Health Company 24

25 NIA Website: Imaging Facilities User-friendly, near-real-time Internet tool offered by NIA o Log on to Website offers access to: o Member prior authorizations Date initiated Exam requested Valid billing codes (CPT) o Helpful resources, including Clinical Guidelines for Radiology Procedures NIA A Magellan Health Company 25

26 To get started, visit 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 address in order for our Webmaster to respond to you with your NIA-approved username and password. Everyone in your organization is required to have his or her own separate username and password due to HIPAA regulations. On subsequent visits to the site, click the Login button to proceed. NIA A Magellan Health Company 26

27 NIA Contact Information NIA Provider Relations Manager: Charmaine Gaymon Phone: Provides educational tools to ordering and rendering providers on imaging processes and procedures. Liaison between HealthPlus Amerigroup Provider Relations and NIA. NIA A Magellan Health Company 27

28 RadMD Demonstration

29 Questions & Answers