Clinical Policies and Procedures for Major Joint and Lower Extremity Services Overview and FAQs for BCBSNC In-Network Providers.

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1 Clinical Policies and Procedures for Major Joint and Lower Extremity Services Overview and FAQs for BCBSNC In-Network Providers October 17, 2016 Overview Blue Cross and Blue Shield of North Carolina (BCBSNC) expanded our agreement with OrthoNet, LLC, to begin prior plan approval (PPA) for major joint and lower extremities services. This agreement is effective January 1, 2017, for our Blue Medicare HMO SM and Blue Medicare PPO SM members. We currently use OrthoNet to provide a uniform, outcome-based set of criteria for the provision of spine surgery and pain management services, and in 2017, OrthoNet will apply this same care management model to major joint and lower extremities services. OrthoNet will be responsible for the prior authorization process and related clinical determinations. This program does not eliminate any current providers from the BCBSNC network. The following questions and answers will help you answer any questions you or your patients may have. Frequently Asked Questions Why is BCBSNC implementing this utilization management (UM) program? We partner with OrthoNet, LLC, to apply their care management model, which: Integrates the needs of providers, members, and BCBSNC Ensures the delivery of high-quality, cost-effective care Reduces health care costs When does the program go into effect? This UM program is effective January 1, What impact, if any, will this program have on providers? The program is designed to provide a uniform, outcome-based set of criteria for the provision of major joint and lower extremity procedures. Prior authorization for these services will be required for our Blue Medicare HMO and Blue Medicare PPO members. What role does OrthoNet play in the authorization of these services? OrthoNet is responsible for the prior authorization process and related clinical determinations for certain major joint and lower extremity procedures for our Blue Medicare HMO and Blue Medicare PPO members. 1

2 Does OrthoNet currently complete some prior authorization services for BCBSNC Medicare Advantage members? Yes. On April 1, 2016, OrthoNet began completing reviews for certain spine and pain management procedures. How does the major joint and lower extremity procedures review program differ from the spine and pain management procedures review program? The programs are very similar, but there are a different set of codes for the new procedures, along with new forms, specific to the new procedure. Reviews will still be conducted using the National Coverage Document (NCD), Local Coverage Document (LCD), and MCG Guidelines (formerly Milliman Care Guidelines), and will follow the same process. OrthoNet s contact numbers (telephone and fax) are also the same. What major joint and lower extremity procedures are included in this program? A list of procedure codes requiring prior authorization from OrthoNet may be found: Are any major joint and lower extremity procedures excluded from this program? The following are excluded from the OrthoNet program: Procedures not on the published BCBSNC-OrthoNet prior authorization code list (see above) Reviews of non-participating provider requests for in-network benefits o Continued stay reviews once OrthoNet provides prior authorization for the hospital stay, and discharge planning for durable medical equipment, home health, and lower levels of care. Are patients required to get a referral from their primary care providers? No. Primary care provider referrals for major joint or lower extremity procedures are not required. Does the setting where the service is provided affect whether or not a procedure requires prior authorization? No. Any services on the OrthoNet prior authorization major joint and lower extremity code list require prior authorization, regardless of the level of care (i.e. outpatient/inpatient.) What happens if a BCBSNC member receives one of these services without prior authorization? Claims submitted for services without prior authorization will be subject to denials of service, based on providers contracts and members Evidence of Coverage. Additionally, services provided without prior authorization may be subject to retrospective medical necessity review. 2

3 How can providers obtain an authorization from OrthoNet? Please follow this process to ensure your request is completed in a timely manner: Download a copy of the appropriate request for authorization form for the major joint and lower extremity procedure at Select the BCBSNC health plan in the provider section. Complete the entire form and include all relevant clinical history, imaging reports, and other pertinent clinical information. Fax everything to (toll-free). If you need to contact OrthoNet directly, please call , 8 am 5 pm, EST. You will be contacted if additional information is required. Why must providers use OrthoNet s request authorization form? Due to the high volume of requests and submissions OrthoNet receives each day, providers are asked to use the OrthoNet authorization form. This ensures timely routing of clinical data to the proper reviewers. What happens after an authorization is submitted? OrthoNet reviews each request and supporting clinical data. They will verify eligibility and benefits, and render a determination, and assign an authorization number, if the procedure is approved. This typically takes approximately 1 2 business days following the receipt of all necessary clinical information. Providers are notified the same day decisions are made. Who reviews authorization requests? Clinical staff, like nurses and physician assistants, with expertise in these areas of practice provide initial authorization reviews. Requests are approved at this level if the clinical guidelines in the NCD, LCD, or MCG guidelines are met. If review requests are unable to be approved at this level, requests are referred to board-certified physicians, with the credentials, training, and experience in the specific clinical services under review. Does an authorization from OrthoNet guarantee coverage for BCBSNC members? Authorizations are for medical certification only, and are not guarantees of benefits. Coverage is subject to BCBSNC payment policies. When should providers begin faxing authorization requests to OrthoNet on behalf of Blue Medicare HMO and Blue Medicare PPO members? Starting January 1, 2017, providers should contact OrthoNet for any new service authorizations with dates of services on or after January 1,

4 What about members already authorized for major joint or lower extremity procedures? Members with authorization provided by BCBSNC for any codes listed on the OrthoNet code list do not require new authorizations. Where should providers submit claims for new major joint or lower extremity procedures? There is no change to the claims submission process. Providers should continue to submit claims to BCBSNC, per the existing process. How can members appeal the determination decision? Members have the right to an appeal, and instructions for filing an appeal are outlined in the denial letters sent to both members and providers. Members or their authorized representatives have the right to request BCBSNC to review decisions by asking us for an appeal, within 60 days of the date of denial. How can providers request appeals with BCBSNC? As a provider, you can file a request for an appeal with BCBSNC on behalf of a member. The request must be in writing, and include: Provider s name Provider s address Member s subscriber ID number Reasons for the appeal Evidence for review, such as medical records, doctors letters, or other information that explains why the service or item is needed. What are the two types of appeals? There are two types of appeals: Standard Appeal BCBSNC provides a written decision on standard appeals within 30 days of receiving the appeals. Our decision may take longer if the member asks for an extension, or if we need additional information about his/her case. We will communicate that we re taking extra time, and will provide an explanation as to why we need more time. Appeals for payments of services already received are provided in writing within 60 days. Fast Appeal BCBSNC provides decisions on fast appeals within 72 hours of receiving the appeals. We will automatically give providers fast appeals for patients whose health could be seriously harmed by waiting up to 30 days for a decision. If we do not provide a fast appeal, we will provide a decision within 30 days. Submitting Appeals to BCBSNC Please mail, fax, or deliver appeals to BCBSNC: For standard appeals: 4

5 o Mailing Address BCBSNC Appeal/Grievance Unit P.O. Box Winston-Salem, NC o Physical Address 5660 University Parkway Winston-Salem, NC o Fax (local) (toll-free) For fast appeals: o HMO Phone o PPO Phone o Fax (local) (toll-free) Contacting OrthoNet Directly Should you need to contact OrthoNet directly, please call Representatives are available Monday through Friday, from 8 am 5 pm (EST). An independent licensee of the Blue Cross and Blue Shield Association. and SM Marks of the Blue Cross and Blue Shield Association. 5