Spine Management Program

NIA Magellan & Presbyterian Health Plan

Training Program

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Program Agenda

• Program

1. Authorization Process

2. Other Program Components

3. Provider Tools and Contact Information

• RadMD Demo

• Questions and Answers

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NIA Highlights

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NIA Facts Industry Presence

Clinical

Leadership

Product Portfolio

• Providing Client Solutions since 1995

• Magellan Acquisition (2006)

• Columbia , MD with 700 National NIA Employees

• Business supported by two National Call Operational Centers

• 55 Health Plan Clients serving 19.5M National Lives

• 10M Commercial; 1M Medicare; 6M Medicaid

• 29 states

• Strong panel of internal Clinical leaders – client consultation; clinical framework

• Supplemented by broad panel of external clinical experts as consultants (for guidelines)

• Advanced Diagnostic Imaging

• Cardiac Solutions

• Radiation Oncology

• OB Ultrasound

• Musculoskeletal Management (Spine Surgery/IPM)

• Sleep Management

• Emergency Department, Provider Profiling & Practice Management Analysis

URAC Certified & NCQA Accredited

Prior Authorization Program • Procedures Performed on or after January 1, 2015 Require Prior Authorization

• NIA’s Call Center & RadMD will open December 29, 2014

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Procedures Requiring Prior Authorization

Inpatient or Outpatient Lumbar & Cervical Spine Surgery

Lumbar Microdiscectomy

Lumbar Decompression (Laminotomy, Laminectomy,

Facetectomy & Foraminotomy)

Lumbar Spine Fusion (Arthrodesis) With or Without

Decompression – Single & Multiple Levels

Cervical Anterior Decompression with Fusion –Single &

Multiple Levels

Cervical Posterior Decompression with Fusion –Single &

Multiple Levels

Cervical Posterior Decompression (without fusion)

Cervical Artificial Disc Replacement

Cervical Anterior Decompression (without fusion)

Emergency Surgery –

admitted via the

Emergency Room

Excluded from Program:

Please note that CPT Codes 22800-22819 used for reconstructive spinal deformity surgery and the associated

instrumentation do not require NIA/Presbyterian Health Plan’s prior authorization. NIA will monitor the use of these CPT

codes in claims, but prior authorization is not currently required. As long as the deformity surgery coded does not include any

CPT codes on NIA’s utilization review matrix, the case will process in claims accordingly.

List of CPT Procedure Codes Requiring Prior

Authorization

• Review Claims/Utilization Review Matrix to determine

CPT codes managed by NIA

• CPT Codes and their Allowable Billable Groupings

• Located on RadMD

• Defer to Presbyterian Health Plan Policies for

Procedures not on Claims/Utilization Review Matrix

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Responsibility for Authorization

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Surgeon

• Responsible for obtaining prior

authorization

Place of Service / Facility

• Ensuring that prior authorization

has been obtained prior to

providing service

Prior Authorization Process - Overview

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Patient and Clinical Information Required

Information for Authorization

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General

Includes things like ordering physician information, member information, place of service, anticipated date of service, clinical information, requested procedure, etc.

Clinical Information

• Clinical Diagnosis

• Physical exam findings and patient symptoms (including findings applicable to the requested procedure)

• Date of onset of pain or exacerbation. Duration of patient’s symptoms.

• Non-operative conservative treatment modalities completed, duration, and results (e.g., interventional pain management procedures, physical therapy , chiropractic or osteopathic manipulation, hot pads, massage, ice packs and/or medication)

• Diagnostic imaging results confirming symptoms and physical exam findings.

• Patient’s Weight/BMI, Tobacco Status and Depression/Mental Health Status

Special Information

• Only one authorization request per spine surgery. Surgeon selects from the list of surgical options—selecting the most complex of the procedures being performed.

• A fusion authorization includes decompression procedures along with instrumentation and bone grafting.

Clinical Foundation & Review - NIA

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Peer-to-Peer Discussion

Clinical Review by NIA’s Specialty Spine Clinicians

Fax/Upload Clinical Information (upon request)

Clinical Algorithms collect pertinent information

Clinical Guidelines Are the Foundation

Clinical guidelines and algorithms were developed by

practicing specialty physicians, literature reviews, and evidence

base. Guidelines are reviewed and mutually approved by

Presbyterian Health Plan and NIA Chief Medical Officers and

Clinical Spine Experts.

When requested, validation of clinical criteria within the patient’s

medical record is required before an approval can be made.

NIA reviews key clinical information to ensure that Presbyterian

Health Plan members are receiving appropriate care prior to

more invasive procedures being performed.

NIA has a specialized clinical team focused on spine care.

Peer-to-peer discussions are offered for any request that does

not meet medical necessity guidelines.

No change in current appeals process.

Our goal – ensure that Presbyterian Health Plan members

are receiving appropriate spine care.

Clinical Guidelines available on www.RadMD.com

NIA to Physician: Request for Clinical

Information

• A fax is sent to the provider detailing

what clinical information that is

needed, along with a Fax Coversheet

• We stress the need to provide the

clinical information as quickly as

possible so we can make a

determination

• Determination timeframe begins after

receipt of clinical information

• Failure to receive requested clinical

information may result in non

certification

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Submitting Clinical Information/Medical

Records to NIA

• Two ways to submit clinical

information to NIA

• Via Fax

• Via RadMD Upload

• Coversheets are sent with all

requests for clinical information

• Coversheets can also be

printed from RadMD or

requested via the Call Center

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Be sure to use the NIA Coversheet for all transmissions of

clinical information including uploads through RadMD!

Specialized Clinical Team: Focused on Spine

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Spine Surgery Reviews

Surgery concierge team will proactively outreach for additional information,

reconsiderations and to schedule peer-to-peer session.

Nurses will assemble surgery cases and reach out for clinical information as needed prior to sending to Surgeon Reviewers

.

Only Orthopedic Spine Surgeons or Neurosurgeons conduct clinical reviews and peer-to-peer discussion on

surgery requests.

Specialized Clinical Team

Notification of Determination

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Authorizations

Validity Period

Authorizations for Spine Surgery are valid for:

• Inpatient: 3 days from

DOS

• Outpatient: 60 day DOS

Denial Notification

Denials

• In the event of a denial,

providers are asked to

follow the appeal

instructions provided in

their denial letter.

Authorization Notification

NIA’s Urgent/Expedited Authorization Process

• Urgent/Expedited Authorization Process

– If an urgent clinical situation exists (outside of a hospital

emergency room), please call NIA immediately.

– The number to obtain a prior authorization is:

1-866-236-8717

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Summary Points: Spine Surgery

• Inpatient and outpatient non-emergent spine surgeries

• Region Specific: Lumbar & Cervical Spine Surgery

• Only one authorization per surgery (most complex performed).

• For example, prior authorization for fusion includes decompression

procedures.

• Date of service is required. NIA must be notified of any changes to the

date of service.

• NIA Spine Surgeons review surgery requests

Please note that CPT Codes 22800-22819 used for reconstructive spinal deformity surgery

and the associated instrumentation do not require NIA/Presbyterian Health Plan’s prior

authorization. NIA will monitor the use of these CPT codes in claims, but prior authorization

is not currently required. As long as the deformity surgery coded does not include any CPT

codes on NIA’s utilization review matrix, the case will process in claims accordingly.

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Spine Surgery Selection - via RadMD

• Only one authorization per

surgery

• Select the most complex

procedure being performed

• Fusion procedures include

decompression,

instrumentation and bone

grafting

• Summary of Surgery CPT

codes available online

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There will be a cheat sheet of definitions and codes

available on RadMD

Provider Tools

• Provider Tools that Make it Easy for Providers to Partner with NIA

Toll free authorization and information number 1-866-236-

8717

Available 8am – 8pm EST

• Interactive Voice Response (IVR) System

RadMD Website – Available 24/7 (except during maintenance)

• Different functionality for ordering and rendering providers

• Request authorization and view authorization status

• Upload additional clinical information

• View Clinical Guidelines, Frequently Asked Questions (FAQs), and

other educational documents

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NIA Website - www.RadMD.com

RadMD Functionality varies by user:

Place of Service / Facility – Views approved authorizations for their

facility

Surgeon – View and submit requests for authorization

Online Tools Accessed through www.RadMD.com:

NIA’s Clinical Guidelines

Frequently Asked Questions

Quick Reference Guides

RadMD Quick Start Guide

Claims/Utilization Matrices

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Dedicated Provider Relations Contacts

NIA Provider Relations Manager

Name: Kevin Apgar

Phone: 800-450-7281 ext. 65050 or 916-859-5080

Email: Kwapgar@magellanhealth.com

Presbyterian Provider Relations Manager

Name: Rebecca Eisenberg

Phone: 505-923-5498

Email: reisenbe@phs.org

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Questions?

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