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Fidelis CareMedical Specialty SolutionsProvider TrainingPresented by:Seth Cohen PT, DPT

NIA Program AgendaIntroduction to NIAOur Program Authorization Process Other Program Components Provider Tools and Contact InformationRadMD DemoQuestions and Answers2

NIA SpecialtyNational Footprint / Medicaid ghtsNational FootprintSince 1995 – delivering radiology69 Medicaid plans/markets with NIA RBMbenefits management solutions; one ofthe go-to care partners in industry.solutions in place.77 health plans/markets – partneringwith NIA for management of advancedand/or cardiac imaging solutions.31.85M national lives –participating in an NIA RBM nationally.12.5M Medicaid lives – in addition to 3.9MExchange and 2M Medicare Advantage livesparticipating in an NIA RBM program nationally.14M Commercial livesIntensive ClinicalSpecialization & BreadthDiverse populations – Medicaid,Exchanges, Medicare, Commercial, FEP,Provider Entities.Specialized Physician Teams 160 actively practicing, licensed, boardcertified physicians 28 specialties and subspecialtiesURAC Accreditation & NCQA Certified3

NIA’s Prior Authorization Program Fidelis Care willbegin a priorauthorizationprogramthrough NIA forthemanagement ofoutpatientimaging,cardiac, physicalmedicine, andradiationoncologyservices.4 Program startdate: October 1,2021 Begin obtainingauthorizationsfrom NIA onSeptember 20,2021 via RadMDor Call Center forservices renderedon or afterOctober 1, 2021.MembershipIncludedProcedures &Settings IncludedImportant DatesThe Program CT/CTACCTAMRI/MRAPET ScanMyocardialPerfusion ImagingMUGA ScanStressEchocardiographyEchocardiography NetworkMedicare MedicaidDual AdvantageEssentialCHPQualified HealthPlansSettings: Office OutpatientHospital NIA will use the FidelisCare network of Inoffice providers, FreeStanding ImagingFacilities (FSFs), andHospitals to deliveroutpatient imagingservices to FidelisCare’s members.

NIA’s Prior Authorization ProgramEffective October 1, 2021: Any services rendered on and after October 1,2021 will require authorization. Only non-emergent procedures performedin an outpatient setting require authorization with NIA.Procedures RequiringAuthorization CT/CTACCTAMRI/MRAPET ScanMyocardial PerfusionImaging MUGA Scan Stress Echocardiography Echocardiography5Excluded from the ProgramProcedures Performed in thefollowing Settings: Hospital InpatientObservationEmergency RoomUrgent CareSurgery Center

List of CPT Procedure Codes RequiringPrior AuthorizationReview Claims/UtilizationReview Matrix to determineCPT codes managed by NIA.CPT Codes and their AllowableBillable Groupings.Located on www.RadMD.com.Defer to Fidelis Care’s Policiesfor Procedures not onClaims/Utilization ReviewMatrix.6

Prior Authorization Process OverviewAlgorithmSubmit RequestsOnline ThroughRadMDwww.RadMD.comOrdering Physician isresponsible for obtainingprior authorization.Information evaluatedvia algorithm andmedical recordsor by PhoneRendering Providerensures an authorizationwas obtained, thenperforms the serviceService AuthorizedRecommendation to Rendering Providers: Do not schedule test until authorization is received7

NIA’s Clinical Foundation & ReviewClinical Guidelines Are the Foundation 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.Clinical Guidelines are available onwww.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. Peer-to-peer discussions are offered for anyrequest that does not meet medical necessityguidelines. Our goal – ensure that members are receivingappropriate care.Clinical Algorithms collect pertinentinformationFax/Upload Clinical Information(upon request)Clinical Review by NIA’s Specialty CliniciansPeer-to-Peer Discussion8

Member and Clinical Information Required forAuthorizationGeneral Includes: ordering physicianinformation, member information,rendering provider information,requested examination, etc.Clinical Information Includes clinical information that willjustify examination, symptoms andtheir duration, physical exam findings Preliminary procedures alreadycompleted (e.g., x-rays, CTs, labwork, ultrasound reports, scopedprocedures, referrals to specialist,specialist evaluation) Reason the study is being requested(e.g., further evaluation, rule out adisorder)Refer to the Prior Authorization Checklists on RadMD for more specific information.9

Clinical Specialty Team ReviewClinical Specialization PodsOverseen by a Physician AdvisorAbdomen/PelvisAutomated Timeliness RoutingNeurology(includes OB-US)CardiacGeneral StudiesOrthopedicRadiation OncologyOncologyPhysician Review TeamPhysician Panel of Board-Certified Physician Specialistswith ability to meet any State licensure requirementsSpecialty Physician panels for peer reviews on specialty products(cardiac, OB ultrasound, radiation oncology, interventional pain management, surgery,sleep management)10

Document ReviewNIA may request member’s medicalrecords/additional clinical information.When requested, validation of clinicalcriteria within the member’s medicalrecords is required before an approvalcan be made.Ensures that clinical criteria thatsupport the requested test are clearlydocumented in medical records.Helps ensure that members receivethe most appropriate, effective care.11

NIA to Ordering Physician: Request forAdditional Clinical InformationA fax is sent to the provider detailingwhat clinical information is needed,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 requested clinicalinformation.Failure to receive requested clinicalinformation may result in noncertification.12

Submitting Additional Clinical Information Records may be submitted: Upload to www.RadMD.com Fax using the NIA coversheet Location of Fax Coversheets: Can be printed fromwww.RadMD.com Call Medicaid, Essential, CHP, andQualified Health Plans:1-800-424-4952 Medicare and Dual Advantage :1-800-424-5390 Use the case specific faxcoversheets when faxing clinicalinformation to NIA13

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 Team interacts withProvider Community.123System Evaluates Request Based onInformation Entered by Physician4NIA Specialty Physician Reviewers NIA Physician approves case withoutpeer to peer Clinical information complete – Procedure Approved Additional clinical information required – Pends forclinical validation of medical recordsKey NIADifferentiatorsPeer-to-peer outbound attemptmade if case is not approvable NIA Physician approves case with peer to peer Ordering Physician withdraws case during peerto peer NIA Physician denies case based on medicalcriteriaGenerally, the turnaroundforreceivecompletionof theserequests is withintwo to24threebusinessdays upon receipt of92% of timecasesfinaldeterminationswithin– 48hourssufficient clinical information.14

NIA Urgent/Expedited Authorization ProcessUrgent/Expedited 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 1-800-424-4952 (Medicaid,Essential, CHP, and Qualified Health) or 1-800-424-5390 (Medicare and DualAdvantage). Outside of business hours, requests should be submitted through RadMD.15

Notification of DeterminationApproval Notification Validity Period - Authorizations are valid for: 60 days from the request date or based on clinical indicationsDenial Notification16 Notifications will include an explanation of what services have been denied and the clinicalrationale for the denial A peer-to-peer discussion can be initiated once the adverse determination has been made. A re-review is available with new or additional information. Timeframe for re-review is 60 calendar days for Medicaid members, 1 year for Medicare andDual Advantage members, and 180 calendar days for Essential, Qualified Health, and CHPmembers from the denial notification. In the event of a denial, providers may appeal the decision by contacting Fidelis Care orfollowing the appeal instructions provided in their determination letter or RemittanceAdvice (RA) notification.

Claims and AppealsHow Claims Should be Submitted Rendering providers/Imagingproviders should continue tosend their claims directly toFidelis Care. Providers are stronglyencouraged to use electronicclaims submission. Check on claims status bylogging on to the Fidelis Carewebsite at:https://providers.fideliscare.org/Login17Claims Appeals Process In the event of a priorauthorization or claimspayment denial, providersmay appeal the decisionthrough Fidelis Care. Providers should follow theinstructions on their denialletter or Remittance Advice(RA) notification.

Radiation Safety and AwarenessStudies suggest a significant increasein cancer in dose estimates in excessof 50 mSvU.S. population is exposed to nearlyfive times more radiation frommedical devices in 2019 than in 1980CT scans and nuclear studies are thelargest contributors to increasedmedical radiation exposureNIA has developed a Radiation Awareness Program designed tocreate member and physician awareness of radiation concerns18

Provider ToolsRadMD Websitewww.RadMD.comAvailable24/7 (except duringmaintenance)Toll Free NumberMedicaid, Essential Plan, CHP, andQualified Health Plans:1-800-424-4952Medicare and Dual Advantage:1-800-424-5390AvailableMonday - Friday8 AM – 8 PM EST19 Request Authorization View Authorization Status View and manage AuthorizationRequests with other users Upload Additional Clinical Information View Requests for additionalInformation and Determination Letters View Evidence based ClinicalGuidelines (by diagnosis) View Frequently Asked Questions(FAQs) Cancer site checklists 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 authorizations for theirfacility.Online Tools Accessed throughwww.RadMD.com: 20NIA’s Clinical GuidelinesFrequently Asked QuestionsQuick Reference GuidesChecklistRadMD Quick Start GuideUtilization 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 email address in orderfor our Webmaster to respond to you withyour NIA-approved 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.2123