Transcript Slide 1

Blue Cross of Northeastern Pennsylvania
(BCNEPA)
Provider Training Program
Provider Training Program Agenda
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Welcome and Opening Remarks
About NIA
The Provider Partnership
The Program Components
The Provider Assessment Program
The Facility Selection Support Program
How the Program Works:
• The Authorization Process
• The Authorization Appeals Process
• The Claims Process
• The Claims Appeals Process
• Provider Self-Service Tools
• NIA Provider Relations and Contact Information
• Questions and Answers
NIA—A Magellan Health Company
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About NIA
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NIA is accredited by
NCQA and URAC certified
National Imaging Associates, Inc.* (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-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; promoting patient
safety through:
• A clinically-driven process that safeguards appropriate diagnostic
treatment for BCNEPA Health Plan members.
*Blue Cross of Northeastern Pennsylvania provides radiology network management services with administrative assistance from
National Imaging Associates, Inc., an independent radiology benefits management company not affiliated with the Blue Cross
and Blue Shield Association.
Blue Cross of Northeastern Pennsylvania administers health care plans offered by Blue Cross of Northeastern Pennsylvania,
Highmark Blue Shield, First Priority Health® and First Priority Life Insurance Company®.
NIA—A Magellan Health Company
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The NIA Provider Partnership Model
• Dedication to provider service and convenience
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Dedicated Provider Relations staff
Authorization call center
Interactive Voice Response (IVR)
Education and training programming
Ongoing outreach to providers – ordering provider surveys, individual
ordering/rendering practice retraining, satisfaction surveys, etc.
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Outpatient Imaging Program Components
• Utilization management/authorizations: 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.
• Ordering provider program: Analyze referral patterns with BCNEPA health
plan and develop additional education and outreach opportunities to the
provider community to review various facility options based upon
convenience factors for members (i.e., free parking, on a public
transportation line, weekend hours, etc.)
• Provider assessment: The program includes privileging for BCNEPA freestanding facilities and in-office providers for advanced imaging services.
The program promotes continuous quality improvement, provides scope of
practice limitations and enables consumers to make educated health care
decisions.
NIA—A Magellan Health Company
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The Provider Assessment
Process for
Rendering Providers
NIA’s Provider Assessment Program
• NIA has a comprehensive program for evaluating imaging providers selected
to participate in the BCNEPA outpatient imaging program
• The NIA Provider Assessment Program:
• Applies a quality assessment process to BCNEPA imaging providers.
• Assures that freestanding facilities (FSF) and interpreting physicians
rendering imaging services meet quality standards.
• Uses an online application process that is easy and convenient for the
imaging providers to complete the quality assessment survey.
• Privileging results are collaboratively reviewed with BCNEPA for all
BCNEPA contracted providers.
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Facility Selection Support
Program
Facility Selection Support Goals
The facility selection process is based on patient support and cost effectiveness.
• Primary consideration is always the clinical aspect of the patient when making
facility recommendations.
• Helps ensure that patients go to quality imaging facilities that are conveniently
located.
• Supports the education of both the provider and patient about cost-effective
facility alternatives.
• Facilitates the delivery of tests at free-standing, outpatient facilities (when
appropriate) to support lower costs.
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How Facilities Are Selected
During prior authorization, the
authorization representative will
help the ordering provider select a
facility based on:
• Facilities meeting NIA’s quality
requirements and patient’s
clinical need
• Location
• Convenience services important
to patient
• Prior authorization for a high-cost
facility will be confirmed with the
consumer if there is no clinical
justification
All facilities meeting NIA’s approved facility
requirements for the indicated test. Facilities
also meet the patient’s clinical requirements.
Facilities located in or close to
required ZIP code. Preference
given to lower cost facilities.
Facilities with
requested
convenience
Items.
Facility
selected.
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Convenience Services that Can Be Selected
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Transportation and parking
• Public transportation accessibility
• Free parking
• Language assistance
• Languages spoken by office staff
• Telecommunication equipment for deaf patients
• Weekend or evening hours
• Extended evening hours
• Weekend hours
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The Authorization Process
NIA Prior Authorization Is Required for:
• Non-Emergent Outpatient:
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CT/CTA/CCTA
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MRI/MRA
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PET scan
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Nuclear cardiology
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Stress echo
• The NIA radiology benefit management program for BCNEPA does not apply
to FPH and FPLIC self-funded employer groups or individual products. It
does apply to CHIP members. Providers will continue to follow the prior
authorization process for radiology services for members of FPH and FPLIC
self-funded groups, as well as members of FPLIC individual products,
currently in place through BCNEPA
• Any code that is specifically cited in the BCNEPA Health Plan-NIA Billable
CPT Codes Claims Resolution Matrix.
• All other procedures will be adjudicated and paid by BCNEPA health plan as
per their payment policy
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NIA Prior Authorization is NOT required:
• When the following studies are performed in an emergency room, urgent
care center, observation or inpatient setting, prior authorization is not
required from NIA.
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CT/CTA/CCTA
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MRI/MRA
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PET scan
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Nuclear cardiology
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Stress echo
• Providers should continue to follow BCNEPA health plan authorization
policies for emergency room, urgent care center, observation or inpatient
procedures.
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NIA’s Authorization Process
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The ordering physician is responsible for obtaining prior authorization.
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The rendering provider must ensure that prior authorization has been obtained and it
is recommended that you not schedule procedures without prior authorization.
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Procedures performed without proper authorization may not be reimbursed.
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If the radiologist or rendering provider feels that, in addition to the study already
authorized, an additional study is needed, either the radiologist or rendering provider
should proceed with the additional study and contact NIA the same business day to
initiate the review process for medical necessity.
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If an urgent clinical situation exists outside of a hospital emergency room, the
radiologist or rendering provider should proceed with the study and contact NIA the
next business day to go through the normal review process.
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Separate prior authorization numbers are not needed for CT-guided biopsy, CTguided radiation therapy and some MR-guided procedures.
NIA—A Magellan Health Company
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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 BCNEPA 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 “Client” 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.
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NIA Clinical UM Authorization Process
Telephone
www.NaviNet.net
Physicians office
contacts NIA for prior
authorization of study
System evaluates request
based on physician
entered information
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Clinical information
complete-procedure
approved
Clinical information
not complete–
additional information
needed
Initial clinical specialty
team review
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Physician review
Additional clinical
information complete–
procedure approved
Additional clinical
not complete or
inconclusive
Request for
specific clinical
information
needed
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Physician approves case
without peer-to-peer
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Physician approves
case with peer-to-peer
W
Ordering physician
withdraws case

Physician denies
case
92% of all cases receive final determinations in 24 – 48 hours.
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The Authorization
Appeals Process
The Authorization Appeals Process
• In the event of a denial or you are not satisfied with a medical decision from
NIA, you may appeal the decision through BCNEPA’s health plan.
• You will receive appeal information in the denial letter that will be sent to you.
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The Claims Process
How Claims Should be Submitted
• Rendering providers/imaging providers should continue to send their claims
directly to BCNEPA’s health plan as per the current process.
• Providers are strongly encouraged to use EDI claims submission.
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The Claims Appeals
Process
The Claims Appeals Process
• In the event of a prior authorization or claims payment denial, you may
appeal the decision through BCNEPA’s health plan.
• Follow the instructions on your non-authorization letter or Explanation of
Benefits (EOB) notification.
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Self-Service Tools and
Usage
Multi-Channel Provider Relations Strategy
Internet Offerings
• Initiate authorization (ordering provider)
• Authorization inquiry
• Privileging
Interactive Voice Response
Radiology
Provider
IVR – Interactive Voice Response
• Authorization inquiry
Provider Relations Staff
• Provider support & inquiries
• 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
Website: www.navinet.net
• Online authorization request/status
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NIA Provider Relations
NIA Contact Information
• NIA Provider Relations Manager
• Charmaine Gaymon
• Phone: (410) 953-2615
• Email: [email protected]
• Provides educational tools to ordering and rendering providers on imaging
processes and procedures.
• Liaison between BCNEPA Provider Relations and NIA.
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Questions and Answers