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Wellcare By AllwellInterventional PainManagement (IPM)Provider Training Presented by:Gina Braswell OTR/LSenior Manager, Provider RelationsPRO 98896E Internal Approved 05042022 Wellcare 2022LA2WCMLTR98896E 0000

National Imaging Associates, Inc. (NIA)1 Program AgendaOur IPM ProgramPrior Authorization Process and Overview Clinical Foundation and Review Clinical Review Process Notification of DeterminationProvider Tools and Contact InformationRadMD DemoQuestions and Answers1National2Imaging Associates, Inc. is an affiliate of Magellan Healthcare, Inc.

NIA Medical Specialty SolutionsNational FootprintNational FootprintMedicaid/MedicareExpertise/InsightsSince 1995 – delivering radiology58 Medicaid plans/markets with Medicalbenefits management solutions; one ofthe go-to care partners in industry.84 health plans/markets –partnering with NIA for management ofMedical Specialty Solutions program.Specialty Solutions in place.2.08M Medicare lives – in addition to17.49 Medicaid lives participating in an NIAMedical Specialty Solutions programnationally.32.57M national lives –participating in an NIA MedicalIntensive ClinicalSpecialization & BreadthSpecialty Solutions program nationally.Diverse populations – Medicaid,Exchanges, Medicare, Commercial, FEP,Provider Entities.Specialized Physician Teams 160 actively practicing, licensed, boardcertified physicians 28 specialties and sub-specialtiesURAC Accreditation & NCQA Certified3

NIA’s IPM SolutionProcedures Performed on or after July 1, 2022, Require PriorAuthorizationNIA’s Call Center and RadMD will open July 1, 2022Targeted IPMProcedures Performed in anOutpatient Facility or OfficeExcluded from the ProgramIPM Procedures Performed in thefollowing Settings: Spinal Epidural Injections Hospital Inpatient Paravertebral Facet JointInjections or Blocks Emergency Room/UrgentCare Facility Paravertebral Facet JointDenervation(Radiofrequency(RF) Neurolysis) Sacroiliac joint injections NIA will use the Wellcare network of Pain Management Physicians, Hospitals and In-OfficeProviders as it’s preferred providers for delivering Outpatient IPM Services to Wellcare byAllwell Medicare members.4

List of CPT Procedure Codes Requiring Prior AuthorizationReview Claims/Utilization ReviewMatrix to determine CPT codesmanaged by NIA.CPT Codes and their AllowableBillable Groupings.Located on www.RadMD.com.Defer to Wellcare Policies forProcedures not onClaims/Utilization Review Matrix.5

Information for Authorization for IPM Injections Every IPM procedure performedrequires a prior authorization. NIA doesnot pre-approve a series of epiduralinjections.SpecialInformation Bi-lateral IPM injections performed onthe same date of service do not requirea separate authorization. Anauthorization will cover bi-lateral as wellas multiple levels on the same date ofservice. Add on codes do not require separateauthorization and are to be used inconjunction with approved primary codefor the service rendered.6

Prior Authorization Process OverviewAlgorithmSubmit RequestsOnline ThroughRadMDwww.RadMD.comOrdering Physician isresponsible for obtainingprior authorization.IPM provider may beboth ordering andrenderingInformation evaluatedvia algorithm andmedical recordsor by PhoneRendering ProviderPerforms Service andensures authorizationwas obtained7Service Authorized

NIA’s Clinical Foundation & ReviewClinical Guidelines Are the FoundationClinical Algorithms collect pertinentinformationFax/Upload Clinical Information(upon request) Clinical guidelines were developed by practicingspecialty physicians, through literature reviewsand evidenced-based research. Guidelines arereviewed and mutually approved by the Plan andNIA Medical Officers and clinical experts. ClinicalGuidelines are available on www.RadMD.com Algorithms are a branching structure thatchanges depending upon the answer to eachquestion. The member’s clinical information/medicalrecord will be required for validation of clinicalcriteria before an approval can be made. NIA has a specialized clinical team focused onIPM. Peer-to-peer discussions are offered for anyrequest that does not meet medical necessityguidelines. Our goal – ensure that members are receivingappropriate care.Clinical Review by NIA’s Specialty CliniciansPeer-to-Peer Discussion8

IPM Clinical Checklist RemindersIPM Documentation:Conservative Treatment Frequently, specifics of conservative treatment/non-operative treatment are not present inoffice notes. Details such as duration and frequency should be provided in order to ensure 6weeks has been attempted within the past 6 months. Official physical therapy records donot need to be obtained but the provider should supply a summary of these details. Physicaltherapy is not the only means of conservative treatment acceptable; physician directedhome exercise programs as well as chiropractic care are among other examples ofappropriate treatments.Visual Analog Scale (VAS) Score and/or Functional Disability A VAS score is an acceptable method to relay intensity of pain. However, a description offunctional disability is also accepted as a means for measuring pain (ie - noting that themember is no longer able to perform work duties, daily care, etc).Follow Up To Prior Pain Management Procedures For repeat treatments, follow up is required in regard to what procedure was completed,how much and for how long relief was obtained, active participation in ongoing conservativetreatment, and to what level the pain has returned. A follow up office visit is not required.Documentation of telephone encounters with the member are acceptable to satisfy thisrequirement.9 9

Sample Pain Rating Scales10

NIA to Physician: Request for ClinicalInformationA fax is sent to the provider detailingwhat clinical information that isneeded, along with a Fax Coversheet.We stress the need to provide theclinical information as quickly aspossible so we can make adetermination.Determination timeframe beginsafter receipt of clinical information.Failure to receive requested clinicalinformation may result in noncertification.11

Submitting Additional Clinical Information Records may be submitted: Upload towww.RadMD.com Fax using that NIAcoversheet Location of Fax Coversheets: Can be printed fromwww.RadMD.com Call 1-855-766-1572 Use the case specific faxcoversheets when faxing clinicalinformation to NIA12

Clinical Specialty Team:Focused on IPMIPM ReviewsInitial clinical reviewperformed by NIAIPM team nurses13The clinical specialtiessupporting our IPMprogram includeanesthesiology and painspecialists

IPM Clinical Review ProcessNIA Initial ClinicalSpecialty Team ReviewPhysicians’ Office ContactsNIA for Prior AuthorizationRadMD Additional clinical information submitted and reviewed –Procedure Approved Additional clinical not complete or inconclusive – Escalate toPhysician ReviewTelephoneDesignated & Specialized Clinical IPM Team interacts withProvider Community.123System Evaluates Request Basedon Information Entered byPhysician & Physician Profile Clinical information complete – Procedure Approved Additional clinical information requiredKey NIADifferentiators4NIA Specialty Physician Reviewers NIA Physician approves case without peer-topeerPeer-to-peer outbound attemptmade if case is not approvable NIA Physician approves case with peer-to-peer Ordering Physician withdraws case duringpeer-to-peer Physician denies case based on medical criteriaGenerally92%the turnaroundfor completionof these requestswithinis within24two– tobusiness daysof cases timereceivefinal determinations48threehoursupon receipt of sufficient clinical information14

NIA Urgent/Expedited IPM Authorization ProcessUrgent/Expedited IPM Authorization Process If an urgent clinical situation exists (outside of a hospital emergency room)during business hours, please call NIA immediately. The NIA Website www.RadMD.com cannot be used for medically urgent orexpedited prior authorization requests during business hours. Those requestsmust be processed by calling the NIA call center at 1-855-766-1572. Turn around time is within 1 Business day not to exceed 72 Business CalendarHours.15

Notification of DeterminationAuthorization Notification Validity Period - Authorizations arevalid for:IMP16 30 days from date of request The date of service that is selected atthe time of the prior authorizationrequest, will be used to determine thevalidity period. If the date of servicechanges, please contact NIA to update.Denial Notification Notifications will include an explanation ofwhat services have been denied and theclinical rationale for the denial A peer-to-peer discussion can be initiatedonce the adverse determination has beenmade. In the event of a denial, providers are askedto follow the appeal instructions providedin their denial letter. Medicare re-opens are not available.

IPM PointsInjections in all regions of spine are managedDate of Service is required for all requestsEach IPM procedure must be prior authorizedNo series of epidural injectionsSpecialty Nurses and Physicians will review IPM requests17

Provider ToolsRadMD Websitewww.RadMD.comAvailable24/7 (except duringmaintenance, performedevery third Thursday of themonth from 9 pm –midnight PST)Toll Free Number1-855-766-1572Available7:00 AM – 7:00 PM CST18 Request Authorization View Authorization Status View and manage AuthorizationRequests with other users Upload Additional Clinical Information View Requests for additionalInformation and Determination Letters View Clinical Guidelines View Frequently Asked Questions (FAQs) View Other Educational Documents Interactive Voice Response (IVR) Systemfor authorization tracking

NIA’s Websitewww.RadMD.comRadMD Functionality varies by user: Ordering Provider’s Office – Viewand submit requests forauthorization. Rendering Provider – Viewsapproved, pended and in reviewauthorizations for their facility. IPM providers are typically both theordering and the rendering provider.Online Tools Accessed throughwww.RadMD.com: 19NIA’s Clinical GuidelinesFrequently Asked QuestionsQuick Reference GuidesIPM ChecklistRadMD Quick Start GuideClaims/Utilization Matrices

Registering on RadMD.comTo Initiate AuthorizationsEveryone in your organization is required to havetheir own separate username and password dueto HIPAA regulations.1STEPS:1.Click the “New User” button on the right side of thehome page.2.Select “Physician’s office that orders procedures”3.Fill out the application and click the “Submit” button. You must include your e-mail address for ourWebmaster to respond to you with your NIAapproved username and password.NOTE: On subsequent visits to the site, click the “Sign In”button to proceed.Offices that will be both ordering and renderingshould request ordering provider access. This willallow your office to request authorizations onRadMD and see the status of those authorizationrequests.2023

RadMD EnhancementsNIA offers a Shared Access feature on our www.RadMD.com website. Shared Access allowsordering providers to view authorization requests initiated by other RadMD users withintheir practice.If practice staff is unavailable for a period of time, access can be shared with other users inthe practice. They will be able to view and manage the authorization requests initiated onwww.RadMD.com, allowing them to communicate with members and facilitate treatment.