Transcript Slide 1

Peach State Health Plan
Ordering Provider Training for OB
Ultrasounds
Ordering Provider Training Program
Agenda for OB Ultrasounds
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Welcome and Opening Remarks
About NIA
The OB Ultrasound Program Requirements
NIA OB Ultrasound Management
Comparison to current OB US Program
The Prior Authorization Process
• The Authorization Appeals Process
• The Claims Process
• 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
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About NIA
NIA is accredited by
NCQA and URAC certified
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National Imaging Associates (NIA) -- chosen as the solution for National
and Regional Health Plans covering more than 19 million lives due to:
• Distinctive clinical focus.
• Accredited by NCQA and URAC certified.
• Innovation and Stability -- Parent is Magellan Health Services – The
depth and breadth of our experience in managing behavioral health
care, diagnostic imaging, specialty pharmaceutical services, pharmacy
benefits administration and obstetrical ultrasounds enables us to deliver
invaluable insights and innovative solutions that positively impact both
the quality and cost of some of the nation’s fastest growing areas of
health care.
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Focus / Results: Maximizing diagnostic services value; promoting patient
safety through:
• A clinically-driven process that safeguards appropriate diagnostic
treatment for Peach State Health Plan members.
NIA—A Magellan Health Company
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The OB Ultrasound
Program and
Authorization Process
OB Ultrasound Program Requirements –Initial Procedures
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Peach State Health Plan and National Imaging Associates, Inc. (NIA) will incorporate
OB Ultrasound procedures into the existing radiology management program effective
December 1, 2010.
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Providers will continue to contact Peach State Health Plan for these procedures
prior to December 1, 2010.
The first one (1) to two (2) OB ultrasounds do not require prior authorization or
registration when standard CPT codes are used.
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Providers can bill one CPT code from any two of the following three groups:
• 76801 or 76817 for the first trimester.
• 76805 or 76811 for second trimester (76811 should only be used for the
second US when the diagnosis is 642.xx, 646.xx, 648.xx or 796.5).
• 76816 for the third trimester (when first US is not done until second trimester)
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One nuchal measure (76813) is also allowed and does not count against the first
one (1) to two (2).
Claims submitted that are outside of the CPT codes noted above will not be paid.
NIA will not be conducting any privileging activities on behalf of Peach State Health
Plan.
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OB Ultrasound Program Requirements –
Beyond Initial Procedures
• OB Ultrasounds beyond the initial one (1) to two (2) require prior
authorization.
• Prior authorization beyond the initial one (1) to two (2) will apply to
the following CPT Codes: 76805, 76811, 76815, 76816, 76817,
76818, 76819, 76820 and 76821.
• When a pregnancy has specific serious complications that meet our
criteria, multiple ultrasounds may be authorized with one request.
• Only Ultrasounds done for confirmed pregnancies will be covered. A
pregnancy test should occur first to confirm the pregnancy.
Ultrasounds to confirm a pregnancy will not be approved.
• Any condition that does not result in an authorization at intake, will
be discussed with an Initial Clinical Reviewer – ICR (such as a
nurse) and/or Physician Clinical Reviewer - PCR ( a Maternal Fetal
Medicine (MFM) specialist) if additional information is needed.
NIA—A Magellan Health Company
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NIA OB Ultrasound Management
NIA’s OB US Management Approach Recognizes Unique Population Challenges
Test
OB
Ultrasound
OB
Ultrasound
Timing of
Procedure
1st or 2nd
After first
1-2
NIA Interface
Potential Outcome
Initial 1-2 scans do not
require prior authorization
or registration when billed
with standard CPT codes.
No Medical
Necessity Denial
Procedures beyond the
initial scans require Prior
Authorization and will be
evaluated via algorithm
and, in some instances,
clinical review.
Procedure may be
authorized. Specific
conditions may result
in authorizations for
multiple procedures
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Comparison to current OB US program
• Both the CURRENT PSHP OB US management program and
the NEW NIA program allow the initial 1-2 procedures without
prior authorization.
• Most pregnancies can be managed with the initial 1-2
procedures.
• A “nuchal measure” is also allowed and does not count against
the first 1-2.
• The NIA program allows the authorization of multiple
ultrasounds for specific, verified medical or obstetrical
conditions, such as diabetes, hypertension, hypothyroid
disease, multiple gestation, etc.
• Many complex pregnancies will only require 1 call.
• Physician reviews, when required, will be conducted by a
Maternal Fetal Medicine specialist.
NIA—A Magellan Health Company
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NIA Prior-Authorization is required for:
• OB ultrasounds beyond the initial procedures previously listed require prior
authorization, including:
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Multiple ultrasounds for specific, verified medical or obstetrical conditions, such
as diabetes, hypertension, hypothyroid disease, multiple gestation, etc.
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Ultrasounds when performed as a component of antepartum testing.
• The standard approach for antepartum testing is a Non-Stress Test (NST)
with, or without an Amniotic Fluid Value (AFV) via a limited ultrasound
(76815) – i.e. “modified biophysical profile”.
• A “full” biophysical profile (NST plus four ultrasound components of Fetal
Movement (FM), Fetal Tone (FT), Amniotic Fluid Volume (AFV) and Fetal
Breath Movement (FBM)) is not considered necessary if the NST is reactive.
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Prior authorization for biophysical profiles (76818 or 76819) is required and
these requests will be clinically reviewed.
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NIA Prior-Authorization is not required for:
• Inpatient OB Ultrasound services
• Observation setting OB Ultrasound services
• Emergency Room OB Ultrasound services rendered in a hospital or
urgent care center
NIA—A Magellan Health Company
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NIA’s Authorization Process
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The ordering physician is responsible for obtaining prior authorization for OB
Ultrasound services beyond the initial one (1) to two (2) ultrasounds and nuchal
measure.
It is the responsibility of the rendering physician (if different than the ordering
physician) to ensure that prior authorization was obtained. Payment will be denied for
procedures performed without prior authorization and the member cannot be balancebilled for such procedures.
The rendering provider must ensure that an authorization has been obtained and it is
recommended that you not schedule procedures without prior authorization.
Authorizations are valid for 30 days from the date of the request. When a procedure is
authorized, NIA will use the date of the request as the starting point for the 30-day
period in which the examination must be completed. For some pregnancies with
specific medical conditions, an authorization for multiple procedures may be valid up to
delivery.
In the event that a service is delivered on an urgent basis in an office setting without
prior authorization, a request can be submitted the same business day or the health
plan will consider information submitted with the claim by the rendering provider (e.g.,
supporting medical records and the reason the service was not prior authorized) when
considering payment of the claim.
Retrospective requests (requests submitted after the day of service) will not be
permitted and will be managed via the Peach State Health Plan claims appeals
process.
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NIA OCR Fax Cover Sheet – Submission
of Clinical Information
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NIA utilizes OCR technology which allows us to attach the clinical information that
you send to be automatically attached to an existing prior authorization request.
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For the automatic attachment to occur you must use the NIA Fax Cover Sheet as the
first page of your fax.
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You can obtain an NIA Fax Cover Sheet in the following ways.
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If you have submitted your prior authorization request on-line through RadMD, at
the end of your submission of the prior authorization request you are given the
option to print the cover sheet.
• On RadMD click on the link “Request a Fax Cover Sheet”. This will allow
you to print the cover sheet for a specific patient.
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By calling the NIA Clinical Support Department at 888-642-7649 you can
request a cover sheet be faxed to you.
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If we have sent you 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
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The NIA Prior Authorization Process
Nurse level
Agent level
Physician’s
office contacts
NIA for prior
authorization
via web or
telephone
P
?
Procedure is
authorized by
agent
Case is
transferred to
nurse for
review
P
?
Procedure is
authorized by
nurse
Case is
transferred to
physician for
review
•When a pregnancy has specific serious complications that meet our criteria, multiple
ultrasounds may be authorized with one request.
•Physician reviewers for OB US Requests are Maternal Fetal Medicine (MFM)
Specialists
MFM/Physician*
level
P
Procedure is
authorized by
a physician
reviewer
x
Procedure is
denied by a
physician
reviewer
x
Case is
administrative
ly withdrawn
by the
ordering
physician
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The Authorization
Appeals Process
The Authorization Appeals Process
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Utilization review decisions are made in accordance with currently accepted medical or healthcare
practices, taking into account special circumstances of each case that may require deviation from the
norm stated in the screening criteria. Criteria are used for the approval of medical necessity but not for
the denial of services. The Medical Director reviews all potential denials of medical necessity decision.
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Appeals related to a medical necessity decision made during the authorization, pre-certification or
concurrent review process can be made orally or in writing to:
Medical Management Administrative Review Coordinator
3200 Highlands Parkway SE, Ste 300
Smyrna, GA 30082
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Providers and members have the right to request a copy of the review criteria or benefit provision utilized
to make a denial decision. Copies of the criteria can be obtained by submitting your request in writing to:
Medical Management
3200 Highlands Parkway, SE, Ste. 300
Smyrna, GA 30082
Attn: IQ Criteria
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Providers may obtain the criteria used to make a specific decision and discuss denial decisions with the
physician reviewer who made the decision by calling the Medical Management Department at 1-800704-1483, Monday - Friday, between the hours of 8am and 5:30 pm.
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The Authorization Appeals Process
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The plan shall allow Medicaid members that have exhausted the internal appeals process related to a denied
service, the option either to pursue the administrative law hearing or to select binding arbitration by a private
arbitrator who is certified by a nationally recognized association that provides training and certification in
alternative dispute resolution.
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If the Medicaid member and the plan are unable to agree on association, the rules of the American Arbitration
Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be
selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code
section 49-4-153 shall be binding on the parties.
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The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the plan
and the Medicaid member mutually agree to extend this deadline. All costs of arbitration, not including attorney’s
fees, shall be shared equally by the parties.
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You must exhaust all of the Plan’s internal Appeals Processes prior to requesting an Administrative Law Hearing
or binding arbitration. All arbitration costs will be shared by the Plan and the Medicaid member.
Requests should be mailed to:
Peach State Health Plan
Manager, Appeals
3200 Highlands Parkway Suite 300
Smyrna, GA 30082
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PeachCare for Kids Members should send their final appeal directly to the Department of Community Health.
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The Claims Process
How Claims Should be Submitted
• Providers should continue to send claims directly to the address indicated
on the back of the Peach State Health Plan member ID card.
• Providers are strongly encouraged to use EDI claims submission.
• Providers should continue to check on claims status by logging on to the
Peach State Health Plan Web site www.pshpgeorgia.com.
NIA—A Magellan Health Company
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The Claims Appeals
Process
The Claims Appeals Process
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In the event of a claims payment denial, providers may file a Reconsideration.
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A provider may also appeal the decision through Peach State Health Plan.
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All Claim appeals require a Provider Appeal Request Form which must be completed and
submitted with supporting documentation. Providers may batch multiple claim appeals that are
similar in nature. The Provider Appeal Request Form may be found in the Provider Forms section
of the Peach State website, www.pshpgeorgia.com. Send Claim Appeals to:
Peach State Health Plan
PO Box 3000
Farmington, MO 63640-3812
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An acknowledgement letter will be sent within ten (10) business days of receipt of the appeal. If
the initial claim determination is upheld, the provider will be notified in writing within thirty (30)
business days of Peach State’s receipt of the claim appeal. If the initial claim determination is
overturned, the provider will be notified through a newly issued EOP.
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If you are still not satisfied with the outcome of the appeal, you have the option of choosing an
Administrative Law Hearing or Binding Arbitration. The request for an Administrative Law Hearing
or Binding Arbitration must be submitted within fifteen (15) days of receipt of the plan’s decision.
Requests received after this time frame will not be considered.
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The Claims Appeals Process
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The plan shall allow a provider that has exhausted the internal appeals process related to a
denied or underpaid claim or group of claims bundled for appeal, the option either to pursue the
administrative law hearing or to select binding arbitration by a private arbitrator who is certified by
a nationally recognized association that provides training and certification in alternative dispute
resolution.
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If the plan and the provider are unable to agree on association, the rules of the American
Arbitration Association shall apply. The arbitrator shall have experience and expertise in the
health care field and shall be selected according to the rules of his or her certifying association.
Arbitration conducted pursuant to this Code section 49-4-153 shall be binding on the parties.
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The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected,
unless the plan and the provider mutually agree to extend this deadline. All costs of arbitration,
not including attorney’s fees, shall be shared equally by the parties.
You must exhaust all of the Plan’s internal Appeal Processes prior to requesting an
Administrative Law Hearing or binding arbitration. All arbitration costs will be shared by the Plan
and the Provider.
Requests should be mailed to:
Peach State Health Plan
Manager, Claim Appeals
3200 Highlands Parkway Suite 300
Smyrna, GA 30082
NIA—A Magellan Health Company
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Self Service Tools and
Usage
Multi-Channel Provider Relations Strategy
Internet Offerings
• Initiate Authorization (Ordering Provider)
• Authorization Inquiry
Interactive Voice Response
OBUS
Provider
IVR – Interactive Voice Response
• Authorization Inquiry
Provider Relations Staff
• Provider Forums/Education
• Centralized and Regional Support
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Self Service Tools and Usage
Interactive Voice Response (IVR)
• Use tracking number to check status of cases
Web site: www.RadMD.com
• Use tracking number to review an exam request
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NIA Website www.RadMD.com
• Information on prior
authorization requests can be
viewed at www.RadMD.com
after login with username and
password
• Providers may search based
on the patient’s ID number,
name or authorization number
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NIA Web Site
• RadMD is a user-friendly, near-real-time Internet tool offered by NIA.
• Hours of Operation: 24/7
• RadMD provides instant access to much of the authorization information
that our Call Center staff provides, but in an easily accessible Internet
format.
• We encourage all ordering providers to submit all requests online at
RadMD.
• With RadMD, the majority of cases will be authorized online with ease;
however, we will resolve pended cases through our Clinical Review
department.
• We strongly recommend that ordering providers print an OCR Fax
Coversheet from RadMD if their authorization request is not approved
online or during the initial phone call to NIA. By prefacing clinical faxes to
NIA with an OCR fax coversheet, the ordering provider can ensure a timely
and efficient case review.
• RadMD provides up-to-the-hour information on member authorizations,
including date initiated, date approved, exam category, valid billing codes
and more.
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NIA Web Site
• User-friendly, near-real-time Internet tool offered by NIA
• Log on to RadMD.com
Web site offers access to:
• Member authorization
• Date initiated
• Exam requested
• Valid billing codes (CPT)
NIA—A Magellan Health Company
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To get started, visit www.RadMD.com
• 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 e-mail address in order for our Webmaster to
respond to you with your NIA-approved user name and password.
• Everyone in your organization is required to have his or her own separate
user name and password due to HIPAA regulations.
• On subsequent visits to the site, click the “Login” button to proceed.
• If you use RadMD for another Health Plan with NIA, you may use the same
log on and password for Peach State Health Plan.
NIA—A Magellan Health Company
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RadMD Demo
NIA Provider Relations
Provider Relations Structure and Portals
• Providing educational tools to ordering providers on OB Ultrasound
program processes and procedures.
• NIA Provider Relations Manager
• Anthony (Tony) Salvati
• Phone: 1-314-387-5537
• Email: [email protected]
• NIA Network Services
• Phone: 1-800-327-0641
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Questions and Answers