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Interventional Pain Management and Spine Surgery

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Interventional Pain Management and Spine Surgery NIA Magellan1 Medical Specialty Solutions Tufts Health Plan Spine Management- Provider Training Presented by: April J. Sidwa Manager, Provider Relations 1NIA Magellan refers to National Imaging Associates, Inc. NIA Training Program 2 NIA Program Agenda •Our Program 1. Authorization Process 2. Provider Tools and Contact Information •RadMD Demo •Questions and Answers Magellan Today and Building for the Future Behavioral • • Behavioral Health Health • • Substance Abuse Solutions • • Integrated Medical & Behavioral Care • • EAP and Health and Wellness Magellan BH • • Psychotropic Drug Management Multiple Solutions One Magellan Pharmacy • • Total Drug Management Solutions • • Medical Pharmacy As the nation’s leading • • Specialty Pharmacy specialty health care Magellan Rx • • Pharmacy Benefits management company, we deliver comprehensive and • Advanced Diagnostic imaging • Cardiac Solutions innovative solutions to • Radiation Oncology improve quality Medical • OB Ultrasound Specialty • Genetic Testing outcomes and • Musculoskeletal Management (Spine Surgery/IPM) Solutions (Chiropractic Care, Speech, Physical and optimize cost of care. Occupational Therapies) NIA Magellan • Sleep Management • Emergency Department • Provider Profiling & Practice Management Analysis 4 NIA Magellan Highlights NIA Magellan Industry Presence Product Portfolio Facts Clinical Leadership • Providing Client Solutions • 76 Health Plan Clients • Strong panel of internal • Advanced Diagnostic since 1995 serving 25.7M National Clinical leaders – client Imaging • Magellan Acquisition (2006) Lives consultation; clinical • Cardiac Solutions • Columbia, MD with 700 • 16M Commercial; 1M framework • Radiation Oncology National NIA Magellan Medicare; • Supplemented by broad • OB Ultrasound Employees • 8.5M Medicaid panel of external clinical experts as consultants (for • Genetic Testing • Business supported by two • 34 states National Call Operational guidelines) • Musculoskeletal Centers Management (Spine Surgery/IPM) • Chiropractic Care, Speech, Physical and Occupational Therapies • Sleep Management • Emergency Department, Provider Profiling & Practice Management Analysis URAC Accreditation & NCQA Certified 5 NIA’s Prior Authorization Program Procedures Performed that require Prior Authorization: Effective August 1, 2015 Procedures Requiring Prior Excluded from Program: Authorization Outpatient/Office Interventional Pain Management-Spine Procedures Performed in the Following Settings: Spinal Epidural Injections, Facet Joint Injections, Facet Joint Denervation/Neurolysis Interventional Pain Management Hospital Inpatient Inpatient and Outpatient Lumbar & Cervical Spine Surgery Observation Room Lumbar Microdiscectomy Emergency Room/Urgent Care Facility Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy) Lumbar & Cervical Spine Surgery Lumbar Spine Fusion (Arthrodesis) With or Without Emergency Surgery – admitted via the Emergency Room 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) Please note that CPT Codes 22800-22819 used for reconstructive spinal deformity surgery and the associated instrumentation do not require NIA/ Tufts Health Plan prior authorization. NIA will monitor the use of these CPT codes, but prior authorization is not currently required. As long as, the deformity surgery coded does not include CPT codes on NIA /Tufts Health Plan prior authorization list, the case will process in Tufts Health Plan 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 Tufts Health Plan Policies for Procedures not on Claims/Utilization Review Matrix Responsibility for Authorization Ordering Providers Facility/Place of Service Responsible for obtaining prior Ensuring that prior authorization has authorization been obtained prior to providing service 8 9 Patient and Clinical Information Required Information for Authorization GENERAL CLINICAL INFORMATION Includes things like ordering physician information, • Clinical Diagnosis member information, place of service, clinical information, requested procedure, etc. • 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. • Conservative treatment modalities completed, duration, and results (e.g., physical therapy , chiropractic or osteopathic manipulation, hot pads, massage, ice packs SPECIAL INFORMATION and/or medication) • Only one authorization request per spine surgery. A • Date and results of prior interventional pain Lumbar fusion authorization includes decompression management procedures, where applicable. procedures. • Diagnostic imaging results, where applicable. • Every interventional pain management procedure • Preliminary procedures already completed (e.g.,, lab performed requires a prior authorization; NIA does not work, scoped procedures, referrals to specialist, pre-approve a series of epidural injections. specialist evaluation) • Date of Service is required NIA’s Clinical Foundation & Review Clinical guidelines were developed by practicing specialty physicians, literature reviews, and evidence base. Guidelines Clinical Guidelines Are the Foundation are reviewed and mutually approved by Tufts Health Plan and NIA Chief Medical Officers and clinical spine experts. Clinical Algorithms collect pertinent Algorithms are a branching structure that change depending upon the answer to each question. information When requested, the patient’s medical record will be Fax/Upload Clinical Information required for validation of clinical criteria before an approval (upon request) can be made. NIA has a specialized clinical team focused on spine care. Clinical Review by NIA’s Specialty NIA reviews key clinical information to ensure Tuft Health Spine Clinicians Plan members are receiving appropriate care prior based on their clinical condition. Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines. Our goal – Peer-to-Peer Discussion ensure that Tuft Health Plan members are receiving appropriate spine care. 11 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 12 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 Be sure to use the NIA Coversheet for all transmissions of clinical information including uploads through RadMD! Clinical Specialty Team: Focused on Spine Specialized ClinicalClinical Specialty Team Team IPM Reviews Spine Surgery Reviews The clinical specialties Surgery concierge Only Orthopedic Spine supporting our IPM team will proactively Nurses will assemble Surgeons or outreach for surgery cases and Initial Clinical Review program include Neurosurgeons additional reach out for clinical conduct clinical Performed by NIA anesthesiology, information, information as needed reviews and peer-to- Neurology Team Nurses orthopedic spine surgeon, reconsiderations and prior to sending to peer discussion on to schedule peer-to- Surgeon Reviewers . neurology, neurosurgeon, surgery requests. and pain specialists peer session. 14 Notification of Determination • Authorization Notification • Denial Notification Authorizations Denials Interventional Pain Management Interventional Pain Management • Validity Period - Authorizations for IPM • You may also follow the appeal process are valid for 60 days from Date of through Tufts Health Plan defined in the Service* (DOS) (will default to date of notice of denial provided to you. request if DOS* not available) Spine Surgery Spine Surgery • You may also follow the appeal process through Tufts Health Plan defined in the • Validity Period notice of denial provided to you. Inpatient Surgeries – 60 days from DOS* Outpatient Surgeries- 60 day from DOS* *The date of service that is selected at the time of the prior authorization request, will be used to determine the validity period. If the DOS changes please contact NIA Magellan to update. 15 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 call to obtain a prior authorization is 1-866-642-9703. 16 Program Components Claims Provider and Network Appeals 17 Provider Network Claims Provider Network and Appeals Provider Network: • NIA Magellan will use the Tufts Health Plan network of Hospitals, Surgery Centers and In Office Providers as it’s preferred providers for delivering Outpatient Interventional Spine Pain Management Services and Inpatient and Outpatient
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