© 2016 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

Chiropractic Services Utilization Management Program for Health Partners Plans

Provider Orientation

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Company Highlights

3k+ employees, including 1k clinicians

100M members managed nationwide

Clients ranging in size from <10k lives

to >10M lives

Headquartered in Bluffton, SC Offices across the US including:

Colorado Springs, CO

Franklin, TN

Greenwich, CT

Lexington, MA

Melbourne, FL

Plainville, CT

Sacramento, CA

12M claims processed annually

SHARING

A VISION AT THE

CORE OF CHANGE.

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Integrated Solutions

CARDIOLOGY

46M lives

RADIOLOGY

65M lives

MUSCULOSKELETAL

34M lives

SLEEP

13M lives POST-ACUTE CARE

145k lives

MEDICAL ONCOLOGY

14M lives

RADIATION THERAPY

22M lives

LAB MANAGEMENT

19M lives

SPECIALTY DRUG

100k lives

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Our Clinical Approach

• 190+ board-certified medical

directors

• Diverse representation of medical

specialties

• 450 nurses with diverse

specialties and experience

• Dedicated team of chiropractic

clinical peer reviewers.

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Clinical Platform

Chiropractic

Internal Medicine

Pediatrics

Sports Medicine

OB/GYN

Cardiology

Nuclear Medicine

Anesthesiology

Radiation Oncology

Sleep Medicine

Oncology/Hematology

Surgery

• General

• Orthopedic

• Thoracic

• Cardiac

• Neurological

• Otolaryngology

• Spine

Radiology

• Nuclear Medicine

• Musculoskeletal

• Neuroradiology

Multi-Specialty Expertise

• American College of Cardiology

• American Heart Association

• American Society of Nuclear Cardiology

• Heart Rhythm Society

• American College of Radiology

• American Academy of Neurology

• American College of Chest Physicians

• American College of Rheumatology

• American Academy of Sleep Medicine

• American Urological Association

• National Comprehensive Cancer Network

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Organic Evidence-Based Guidelines

The foundation of our solutions:

• American College of Therapeutic Radiology and

Oncology

• American Society for Radiation Oncology

• American Society of Clinical Oncology

• American Society of Colon and Rectal Surgeons

• American Academy of Orthopedic Surgeons

• North American Spine Society

• American Association of Neurological Surgeons

• American College of Obstetricians and Gynecologists

• The Society of Maternal-Fetal Medicine

Aligned with National Societies

Dedicated

pediatric

guidelines

Contributions

from a panel

of community

physicians

Experts

associated

with academic

institutions

Current

clinical

literature

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Service Model

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Why Our Service Delivery Model Works

One centralized intake point

allows for timely identification,

tracking, trending, and reporting

of all issues. It also enables

eviCore to quickly identify and

respond to systemic issues

impacting multiple providers.

Complex issues are escalated

to resources dedicated to

specific providers who are the

subject matter experts and can

quickly coordinate with matrix

partners to address issues at a

root-cause level.

Routine issues are handled by

a team of representatives who

are cross trained to respond to a

variety of issues. There is no

reliance on a single individual to

respond to your needs.

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Chiropractic Services

Utilization Management Program

for Health Partners Plans

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Chiropractic Services Policy

Description Criteria Limitations Admin.

Guidelines

The Medical Assistance

Program provides payment for

specific chiropractors’ services

rendered to eligible recipients

by chiropractors enrolled as

providers under the program.

Chiropractic care is considered

covered for manual manipulation

of the spine to adjust misaligned

or displaced vertebrae.

The following are not covered:

• Treatment other than manual

manipulation of the spine to

correct a subluxation

• Physical therapy

• Traction procedures

• Physical examinations

• Consultations

• Inpatient services

Submission of a Chiropractic

Services Treatment Plan form is

required.

Treatment frequency should be

consistent with the severity of

the patient’s condition.

eviCore will begin accepting requests on 7/25/2016 for dates of service

8/1/2016 and beyond

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Program Overview

Authorization for treatment applies to services:

• Starting with the patient’s initial visit

It is the responsibility of the rendering provider to request

precertification for services.

Applicable Membership

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Authorization is required for members enrolled in the following programs:

• HealthChoices Medicaid

Members who do not require authorization are

• The Children’s Health Insurance Program (CHIP)

• Health Partners Medicare*

*Authorization of Chiropractic Services will be effective 1/1/2017 for Health Partners Medicare

Two ways to request authorization:

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Authorization Requests

888-565-4225

For questions regarding the

Chiropractic Services Treatment Plan

form, you may call eviCore’s Customer

Service at: 877-531-9139

http://www.lmhealthcare.com/

Available 24/7 and the quickest

way to submit authorization and

check existing case status.

To register, call 877-531-9139

WEB

FAX

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Needed Information

Member Member ID

Member name

Member address

Date of birth (DOB)

Rendering Provider Rendering provider name

Tax identification number (TIN)

Fax number

Street Address

i Requests All clinical findings

requested on the

Chiropractic Services

Treatment Plan form,

related to spinal

conditions, are required

for review.

If clinical information is needed, please be able to supply:

• Patient’s subjective complaints, objective examination findings, and level of function

• Information from the Chiropractic Services Treatment Plan form

• Office notes are optional as the needed clinical information is contained in Chiropractic

Services Treatment Plan form

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Chiropractic Services Treatment Plan

• The Chiropractic Services Treatment Plan is designed to assist with the

submission of patient and practitioner information for medical necessity

review.

• This treatment plan form should be completed by the practitioner during the

initial consultation and treatment planning, collecting the clinical information

to allow for ease of submission.

• The Chiropractic Services Treatment Plan form is available through our web

portal and is specific to Chiropractic services.

• Services should not be requested more than 7 days prior to the proposed

Start Date. Requesting care too far in advance does not allow you to report

up-to-date clinical findings.

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Chiropractic Services Treatment Plan Form

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Chiropractic Services Treatment Plan

Patient & Provider Information Member ID

Member name

Member Address

Date of birth (DOB)

Rendering Provider Rendering provider name

Tax identification number (TIN)

Fax number

Street Address

• Requests for authorization must be submitted on an eviCore

Chiropractic Services Treatment Plan.

• Patient and Rendering Provider demographic information is

completed for you when you submit authorization requests via

the Web.

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Chiropractic Services Treatment Plan

Clinical Findings All clinical findings on the Chiropractic Services Treatment Plan

form, referenced above, related to spinal conditions, are required

for review.

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Chiropractic Services Treatment Plan

Clinical Findings All clinical findings on the Chiropractic Services Treatment

Plan form, referenced above, related to spinal conditions,

are required for review.

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Review Determination Outcomes

• It is our business practice to complete requests

within 2 business days from the receipt of complete

clinical information.

• Authorizations are typically good for 30 calendar

days from the date of determination.

Approved Requests:

• Faxed to rendering provider

• Mailed to the member

• Information can be printed on demand from the

eviCore Provider Portal, Landmark Connect

Delivery:

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Review Determination Outcomes

• Communication of denial determination

• Communication of the rationale for the denial

• How to request a Peer Review

Denied Requests:

• Faxed to the rendering provider

• Mailed to the member

• Determination letters are available on Landmark

Connect

Delivery:

• Rendering Chiropractors will have the option to

speak with an eviCore clinical peer reviewer during

the adverse determination process. Details will be

provided in the Review Determination Letter.

Peer-to-Peer Review:

• eviCore healthcare is not delegated to handle

clinical appeals.

• Your determination letter will provide you with

information regarding how to appeal denied

services with Health Partners Plans.

Appeals:

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Approved Time Period

• Care is typically approved for 30 calendar days from the requested start date and

allows the practitioner to assess the patient’s response to treatment. The duration

of the authorization is known as the Approved Time Period.

• Visits should be spread throughout the authorized duration to avoid a gap in care

at the end of the Approved Time Period.

• Submit an updated treatment plan to request continuing care if more visits are

medically necessary after the Approved Time Period expires.

o If the member has a setback or complication, you may request additional visits

within an existing Approved Time Period. To do so, you must submit a new

Chiropractic Services Treatment Plan form with updated clinical findings.

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Date Extension

• An extension may be necessary due to unforeseen delays, such as your patient’s

inability to attend all scheduled visits.

o One date extension, up to 30 days beyond the authorization end date, will be allowed

per authorization for patients aged 21 years and over.

o Two date extensions, up to 30 days each beyond the authorization end date, will be

allowed per authorization for patients under the age of 21.

• You may submit a Date Extension by using the Date Extension Request e-Form

on the Provider Portal, or download the Date Extension Request Form and fax it

to 888-565-4225.

• You must request your date extension within 30 days from the End Date of the

Approved Time Period if you want to extend.

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Provider Resources

Web-Based

Services

Documents

Provider Resources: Customer Service

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8:00 AM - 5:00 PM (Eastern Time): (877) 531-9139

• Obtain assistance with web registration

• Check the status of an existing authorization

• Discuss questions regarding authorizations and case decisions

• Obtain information specific to treatment submissions, extensions

and utilization management policies

eviCore fax number: (888)-565-4225

Customer Service

Department

Web-Based

Services

Documents

Provider Resources: Web-Based Services

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Customer Service

Department

Landmark Connect

For assistance with the Provider Portal, contact Customer Service at

(877)-531-9139.

Our Provider Portal allows you to: • Complete self-registration

• Request authorization and check status online – 24/7

• View Determination Letters

• View Program Specific Information, including FAQ documents

and other program-related material

Web-Based

Services

Documents

Provider Resources: Implementation Document

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Customer Service

Department

Please visit Landmark Connect to access the following program materials.

Provider Portal Site:

• Chiropractic Utilization Management Guide

• Frequently Asked Questions resource document

To obtain a copy of this presentation, please contact

clientservices@evicore.com

Program Criteria:

• Chiropractic Guidelines – Chiropractic Services

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Thank You.