Prior Authorization Of Radiology & Cardiology For WellCare

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Company HighlightsHeadquartered in Bluffton, SC4K employeesincluding 1K cliniciansOffices across the US including: Lexington, MA Melbourne, FL Colorado Springs, CO Plainville, CT Franklin, TN Sacramento, CA Greenwich, CTSHARINGA VISIONAT THE CORE OF CHANGE.100M membersmanaged nationwide12M claimsprocessed annually2

Integrated SolutionsLAB MANAGEMENT19M livesMEDICAL ONCOLOGY14M livesRADIATION THERAPY22M livesMUSCULOSKELETAL35M livesSPECIALTY DRUG100k livesRADIOLOGY65M livesSLEEP13M livesCARDIOLOGY46M livesPOST-ACUTE CARE320k lives3

Our Clinical Approach4

Clinical PlatformMulti-Specialty Expertise Family MedicineOncology/HematologyInternal MedicineSurgeryPediatricsSports MedicineOB/GYNCardiology yngologySpineNuclear MedicineRadiologyAnesthesiologyRadiation OncologySleep Medicine Nuclear MedicineMusculoskeletalNeuroradiology190 board-certified medicaldirectors Diverse representation of medicalspecialties 450 nurses with diversespecialties and experience Dedicated nursing and physicianteams by specialty forCardiology, Oncology, OB-GYN,Spine/Orthopedics, Neurology,and Medical/Surgical5

Organic Evidence-Based GuidelinesThe foundation of our iatedwith academicinstitutionsContributionsfrom a panelof d with National Societies American College of Cardiology American College of Therapeutic Radiology andOncology American Heart Association American Society of Nuclear Cardiology American Society for Radiation Oncology Heart Rhythm Society American Society of Clinical Oncology American College of Radiology American Society of Colon and Rectal Surgeons American Academy of Neurology American Academy of Orthopedic Surgeons American College of Chest Physicians North American Spine Society American College of Rheumatology American Association of Neurological Surgeons American Academy of Sleep Medicine American College of Obstetricians and Gynecologists American Urological Association The Society of Maternal-Fetal Medicine National Comprehensive Cancer Network6

Service Model7

Client Provider OperationsThe Client Provider Operations team is responsible for high-level service delivery toour health plan clients as well as ordering and rendering providers nationwideBest ColorsClient ProviderRepresentativesClient ProviderRepresentativesare cross-trained toinvestigate escalatedprovider and healthplan issues.Client ServiceManagersRegional ProviderEngagement ManagersClient Service Managerslead resolution ofcomplex service issuesand coordinate withpartners for continuousimprovement.Regional Provider EngagementManagers are on-the-groundresources who serve as the voice ofeviCore to the provider community.8

Why Our Service Delivery Model WorksOne centralized intake pointallows for timely identification,tracking, trending, and reportingof all issues. It also enableseviCore to quickly identify andrespond to systemic issuesimpacting multiple providers.Complex issues are escalatedto resources who are thesubject matter experts and canquickly coordinate with matrixpartners to address issues at aroot-cause level.Routine issues are handled bya team of representatives whoare cross trained to respond to avariety of issues. There is noreliance on a single individual torespond to your needs.9

Prior Authorization Programfor WellCare10

Program OvervieweviCore will begin accepting requests on 1/1/17 for dates of service1/1/17 and beyond.Prior authorization appliesto services that are:Prior authorizationdoes not apply to servicesthat are performed in: Outpatient Emergency room Inpatient Observation UnitsIt is the responsibility of the ordering provider to request priorauthorization approval for services.11

Prior AuthorizationPrior Authorization is required for WellCare Nebraska membersenrolled in the following programs: Radiology and CardiologyCT, PET, PET CT, MRI, MRA,Nuclear Medicine, OB UltrasoundDiagnostic Heart Catheterization(DHC), Nuclear Stress Testing, EchoStress Testing, TransthoracicEchocardiography, Cardiac Imaging,Cardiac CT, Cardiac MRI, CardiacPET12

Prior Authorization RequestsHow to request prior authorization:www.evicore.comAvailable 24/7 and the quickestway to create prior authorizationsand check existing case statusWEBOr by phone:888.333.86417:00 a.m. to 7:00p.m. localMonday - Friday13Fax option: 888.693.3210 Fax forms available at: www.evicore.com

Clinical Review ProcessMethods of IntakeSTARTPredictiveIntelligence/ClinicalDecision SupportReal-Time Decision with WebNurseReviewAppropriateDecisionEasy forprovidersand staffMDReviewPeer-topeer14

Needed InformationMemberRendering FacilityMember IDMember nameDate of birth (DOB)Referring/Ordering PhysicianPhysician nameNational provider identifier (NPI)Tax identification number (TIN)Fax numberFacility nameNational provider identifier (NPI)Tax identification number (TIN)Street addressiRequestsCPT code(s) forrequested imagingThe appropriatediagnosis code for theworking of differentialdiagnosisIf clinical information is needed, please be able to supply: Prior tests, lab work, and/or imaging studies performed related to this diagnosis The notes from the patient’s last visit related to the diagnosis Type and duration of treatment performed to date for the diagnosis15

Prior Authorization OutcomesApproved Requests: All requests are processed within 2 business daysafter receipt of all necessary clinical information.Authorizations are typically good for 90 calendardays from the date of determination. Delivery: Faxed to ordering providerInformation can be printed on demand from theeviCore healthcare Web Portal16

Prior Authorization OutcomesDenied Requests: Communication of denial determinationCommunication of the rationale for the denialHow to request a Peer ReviewDelivery: Faxed to the ordering providerMailed to the memberInformation can be printed on demand from theeviCore healthcare Web Portal Ordering provider has the option to request a peerto-peer conversation with an eviCore healthcarephysician, resulting in an overturn or an uphelddenial. WellCare will be delegated for first level memberand provider appeals.Peer-to-Peer Review:Appeals:17

Web Portal Services18

eviCore healthcare website Point web browser to evicore.com Click on the “Providers” link Login or Register

Creating An AccountTo create a new account, click Register.20

Creating An AccountSelect a Default Portal, and complete the registration form.21

Creating An AccountReview information provided, and click “Submit Registration.”22

User Registration-ContinuedAccept the Terms and Conditions, and click “Submit.”23

User Registration-ContinuedYou will receive a message on the screen confirming your registration issuccessful. You will be sent an email to create your password.24

Create a PasswordYour password must be atleast (8) characters longand contain the following:Uppercase lettersLowercase lettersNumbersCharacters (e.g., ! ? *)25

Adding PractitionersClick “Yes, Associate Practitioner(s) Now” and add the practitioner informationrequested: NPI, State, and Zip Code.26

Adding PractitionersSelect the matching record based upon your search criteria27

Manage Your Account Once you have selected a practitioner, your registration will be completed.You can then access the “Manage Your Account” tab to make any necessaryupdates or changes. You can also click “Add Another Practitioner” to add another provider to youraccount.28

Initiating A Case Once registered, providers are granted access to the web portal. After logging into your account, a welcome screen provides options. Choose“request a clinical certification/procedure” to begin a new case request.29

Select ProgramSelect the Program for your certification.30

Select Referring PhysicianSelect the Practitioner/Group for whom you want to build a case.31

Select Health PlanChoose the appropriate Health Plan for the case request.32

Select Address33

Contact InformationEnter the Physician’s name andappropriate information for thepoint of contact individual.34

Member InformationEnter the member information including the Patient ID number, date of birth, andpatient’s last name. Click “Eligibility Lookup.”35

Clinical Details36

Verify Service Selection37

Site Selection Verify all information entered and make any needed changes prior to movinginto the clinical collection phase of the prior authorization process. You will not have the opportunity to make changes after that point.38

Pause/Save OptionOnce you have entered the clinical collection phase of the case process, you can savethe information and return within (2) business days to complete.39

Medical ReviewIf additional information is required, you will have the option to either uploaddocumentation, enter information into the text field, or contact us via phone.40

ApprovalOnce the clinical pathwayquestions are completedand the answers have metthe clinical criteria, anapproval will be issued.Print the screen and storein the patient’s file.41

Building Additional CasesOnce a case has been submitted for clinical certification, you can return to the MainMenu, resume an in-progress request, or start a new request. You’re even able toindicate if any of the previous case information will be needed for the new request.42

Authorization Look Up43

Authorization Status44

Eligibility Look Up45

Provider Resources46

Radiology/Cardiology Online ResourcesClinical Guidelines, FAQ’s, Online Forms, and other important resources can beaccessed at www.evicore.com. Click “Solutions” from the menu bar, and select thespecific program needed.47

Provider Resources: Pre-Certification Call CenterPre-CertificationCall CenterWeb-BasedServices7:00 AM - 7:00 PM (Local Time): 888-333-8641 Obtain pre-certification or check the status of an existing case Discuss questions regarding authorizations and case decisions Change facility or CPT Code(s) on an existing caseProvider RelationsDepartmentDocuments48

Provider Resources: Web-Based ServicesPre-CertificationCall CenterWeb-BasedServiceswww.evicore.comTo speak with a Web Specialist, call (800) 646-0418 (Option #2) oremail portal.support@evicore.com.Client ProviderOperations Request authorizations and check case status online – 24/7Pause/Start feature to complete initiated casesUpload electronic PDF/word clinical documentsDocuments49

Provider Resources: Client Provider OperationsPre-CertificationCall CenterWeb-BasedServicesclientservices@evicore.com Client ProviderOperations Eligibility issues (member, rendering facility, and/or orderingphysician)Questions regarding accuracy assessment, accreditation, and/orcredentialingIssues experienced during case creationRequest for an authorization to be resent to the health planDocuments50

Provider Resources: Implementation DocumentProvider Enrollment Questions Contact WellCarePre-CertificationCall CenterWellCare Implementation Web-BasedServices Fact sheetsQuick reference guide linkseviCore clinical guidelinesProvider RelationsDepartmentCoding Guidelines & Program Criteria:https://www.evicore.com/DocumentsTo obtain a copy of this presentation, please contact theProvider Relations department at providerrelations@evicore.com51

Thank You!52

American College of Chest Physicians American College of Rheumatology American Academy of Sleep Medicine American Urological Association National Comprehensive Cancer Network 6 Organic Evidence-Based Guidelines The foundation of our solutions: American College of Therapeutic Radiology and Oncology