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National Imaging Associates, Inc. (NIA)Frequently Asked Questions (FAQ’s)For the Post Service Therapy Review ProgramFor Home State Health Plan ProvidersQuestionAnswerGeneralWho is National ImagingAssociates, Inc. (NIA)?NIA is a specialty healthcare management companywhich delivers comprehensive and innovative solutionsto improve quality outcomes and optimize cost of care.NIA is managing post service therapy requests as ofFebruary 1, 2018. This is not a prior authorizationprogram.When did this PostService Therapy Reviewprogram begin?Effective February 1, 2018, NIA may request clinicaldocumentation to support the medical necessity andappropriateness of the care. There is no need to sendpatient records at this time. NIA will notify you if recordsare needed. Physical, Occupational and SpeechTherapy claims will be reviewed by NIA peer consultantsto determine whether the services met/meet Home StateHealth Plan’s policy criteria for medically necessary andmedically appropriate care.Why did Home StateHealth Plan implement aPost Service TherapyReview Program?We implemented a post service review program toensure patients are receiving the right care, in the rightplace, at the right time. This includes ensuring the carerendered is in compliance with standard therapy practiceand evidence based practice, is provided at theappropriate intensity, and that this care is supported bymedical records.This is not a prior authorization program, you do notneed to send in clinical information unless it isrequested.1—Home State Health Plan - Frequently Asked Questions

Does NIA require priorauthorization of theseservices?No. This is a post-service review only. Priorauthorization is not required by either NIA or Home StateHealth Plan for therapy as of February 1, 2018.Do out of networkproviders require priorauthorization for therapyservices?Out of network providers must contact Home StateHealth Plan to (register) prior to rendering therapyservices. Any services rendered by out of networkproviders are still subject to post-service review.What therapies does NIAreview post service?NIA is managing Physical, Occupational and Speechtherapies post service.How many therapy visitscan a member havebefore the claims go tomedical review?Providers need to ensure that the member has notexhausted his/her Physical, Occupational and SpeechTherapies’ benefit and/or has a habilitative benefit priorto providing services. Please contact Home StateHealth Plan for member benefits. The purpose of NIA isto review medical necessity of Physical, Occupationaland Speech services, and not to manage the member’sbenefits.This program is not a prior authorization program;therefore these services will not require priorauthorization when performed by a participatingprovider. NIA will notify you if clinical documentation,which would include the original evaluation is needed.Providers will be able to upload requested documentson the NIA website (www.RadMD.com) or via fax at 1800-784-6864.If no prior authorization isneeded, do originalevaluations need to besent? If so, where arethey sent?Post Service ReviewProcessHow are providersnotified if medicalrecords/clinicalinformation is needed forthe therapy services?If clinical information/medical records are needed, theprovider will be notified via fax and telephonically. Threeattempts will be made by NIA to obtain this informationbefore the claim is denied for lack of information. In thecase of a lack of information denial, please submit theclinical information requested as soon as possible formedical necessity review and potential adjustment of thedenied claim. If the provider disagrees with the NIAdetermination after the receipt and review of clinicalinformation, a reconsideration can occur within 48 hours.The appeal rights are outlined in all denial notifications.2—Home State Health Plan - Frequently Asked Questions

I think NIA may have anincorrect fax number formy office, How do Ichange the fax number soI receive faxes from you?It is important that NIA have the correct fax number foryou to receive requests for clinical information/medicalrecords. You may send the updated fax number tofollowing email address:How much time isallowed to return therequested informationbefore the claim is deniedfor lack of information?Providers have five days from the date of notification tosend NIA their clinical information/medical records.How do providers submitmedical records to NIA?Medical records can be uploaded onto RadMD or faxedto: 1-800-784-6864.The fax you receive requesting information will include afax coversheet. You will also receive a tracking numberfor your case whenever records are requested. You canuse this tracking number on RadMD to upload yourrecords and/or to find out more information on the case,including additional member and case identifiers.The following information will be required when NIA isrequesting clinical information:What information isrequired when NIArequests the patients’medical nhealth.com Therapy Order/Referral (if required)Name and office phone number of ordering physicianMember name and ID numberPertinent therapy records including the initialevaluation, any re-evaluations, recent treatmentnotes, a recent progress note, and/or a dischargesummaryDocumentation such as progress notes and/or adischarge summary from a recent or concurrentepisode of careAll documentation must comply with ClinicalGuideline: Record Keeping and DocumentationStandards. This includes, but is not limited to:o Inclusion of appropriate patient history,diagnosis, prognosis and rehab potentialo Objective tests and measureso Treatment goals and a plan of care includingfrequency and duration of services providedo Additionally, these items must be updated ona regular basis and included as part of atherapy progress note3—Home State Health Plan - Frequently Asked Questions

How do providers uploadclinical information onRadMD.com?Where do providers sendtheir therapy claims?To upload clinical information/medical records onRadMD, follow this procedure:1) Enter the tracking number provided in the ‘Track anAuthorization’ look-up tool (in upper right quadrant ofthe RadMD home page).2) Click on the ‘Go’ button.3) If a warning message appears that states “This is anNIA computer system for the use of authorizedusers ”, click on “OK”.4) RadMD presents the information for that trackingnumber (no patient information is shown):a) Procedureb) Physician namec) Date requested (which may the date the reviewwas requested or the date that the request forrecords was created)5) Click the “Upload Document” link (under the“date/status” section).6) System presents the “Verify the Patient ” page;Complete the following required fields:a) Patient’s Last Nameb) Patient’s First Namec) Patient’s Date of Birth7) Click on “Continue to Upload Additional ClinicalInformation”.8) On the “Upload Additional Clinical Information” page,click the “Browse”’ button.9) Find the desired file in your system.a) Medical records need one of the followingextensions: .doc, .gif, .png, .jpg, .tif, .tiff, .pdf, .txtb) Digial images will have either a .dcm or .zipextension (multiple images should be in a zip file)c) Click ‘Open’ button; RadMD system presents thefile path and file name in the text field10) Click on the “Upload Document” button. The uploadprocess may take several minutes, depending onyour internet connection speed. You should be ableto do other tasks on your system while the upload isin process.When upload is successful, RadMD will present thefollowing message to user: “You have successfullyuploaded the following file to National ImagingAssociates: filename ”Providers will not send claims directly to NIA. All claimsshould continue to be submitted to Home State HealthPlan. It is important that the provider submits the claims4—Home State Health Plan - Frequently Asked Questions

as soon as possible so the review process can begin.Failure to submit records will result in an insufficientinformation denial.What is the timeframe forreceiving a determinationfrom NIA from the time aclaim is pended forreview?Where did NIA’s medicalpolicy/clinical guidelinescome from?A determination (approval, medical necessity denial, orinsufficient denial) will be issued within 5 calendar daysof NIA pending the claim for review. As of 3/16/18, thetimeframe has been extended to 14 calendar days,which will allow providers more time to submit clinicaldocumentation to NIA. We encourage you to submitthese records timely upon receipt of a request forrecords from NIA to allow adequate time for peer reviewand discussion as necessary.NIA leverages both internally developed and nationallyrecognized externally contracted guidelines. Ourinternally developed guidelines have been developed bya board of clinical specialists, including physicians andtherapists, in conjunction with other client health plansand professional organizations. Our contractedguidelines, through Apollo Managed Care, consolidateand continuously update the most recent and highestquality literature to establish and defend standardtherapy practice. NIA Clinical Guidelines can beaccessed at www.RadMD.com.Are clinical guidelinesavailable?NIA’s Clinical Guidelines are available on RadMD byselecting Solutions and then Physical Medicine at thetop of the page. Web ine.aspxWho is performing theclinical reviews and whattype of credentials andexpertise do thereviewers have?The clinical reviews are performed by NIA reviewers,who are all specialty-matched peers. This includeslicensed and practicing Physical Therapists,Occupational Therapists, Speech LanguagePathologists and Physicians with backgrounds in variousrelevant clinical settings (i.e. pediatrics, orthopedics,school-based therapy, home care, neurology, etc.).What type of providersettings are subject tothis post service therapyreview?All outpatient therapy services which may include thefollowing places of service: outpatient office, outpatienthospital and home health (under outpatient benefit only).5—Home State Health Plan - Frequently Asked Questions

Reconsideration andClaims Process forTherapy ManagementWhat if the therapistdisagrees with NIA’sdetermination?Prior to any medical necessity denial, we offer a peer-topeer discussion with one of our specialty matched peerreviewers. We also will informally engage with providersduring the review process at times prior to making adenial recommendation. If after a determination is made,the provider disagrees with the determination, there maybe a window in which a reconsideration can occur within48 hours. Finally, the appeal rights are outlined in alldenial notifications.What is the appealsprocess?Claim appeals are handled by Home State Health Plan.Medical necessity appeals are managed by NIA,providers should follow the process outlined in the letter.If the denial was for insufficient clinical information orfailure to submit medical records to NIA, providers canfax records with the original fax cover sheet to NIAwithin 180 calendar days of the adverse determinationwithout going through the formal appeals process.How does this programimpact claims paymentfor these services?The claims payment process does not change. Claimsare still submitted to the Home State Health Plan andprocessed within the required time frame. One of threedeterminations will be reached for any claim that pendsfor review: Meets medical necessity/approved Does not meet medical necessity/denied Insufficient information received/deniedDo all claims pend?No. Our data driven claims analysis incorporates patientand provider information to identify a subset of claims forclinical validation/records review. Pending of a claimdoes not necessarily indicate a risk of denial, it simplymeans clinical validation is required to support theservices billed.Is a claim initiallyconsidered pended ratherthan denied?Yes.6—Home State Health Plan - Frequently Asked Questions