Transcription
Gateway Health and GatewayMedicare Assured Medical Specialty SolutionsMusculoskeletal (MSK) Management &Interventional Pain Management(IPM) ProgramsSEPTEMBER 2019Presented by:
Magellan Healthcare Training Program2
Magellan Healthcare Program AgendaOur Program1. Authorization Process2. Other Program Components3. Provider Tools and Contact InformationRadMD DemonstrationQuestions and Answers3
A Unique Vision of CareAs the nation’s leading specialty health care management company, we delivercomprehensive and innovative solutions to improve quality outcomes andoptimize cost of care. 20% clinicaldisapprovalNational Imaging Associates, Inc. (NIA) is an affiliate of Magellan Health Servicesrates44
Magellan FactsMagellan Facts Providing Client Solutionssince 1995 Magellan Acquisition (2006) Headquartered inScottsdale, AZ Business supported by twoNational Call OperationalCentersIndustry Presence 77 Health Plan Clientsserving 27.37 millionNational Lives 15.01 millionCommercial 1.90 million Medicare 10.47 million Medicaid 42 statesProduct PortfolioClinical Leadership Strong panel of internalClinical leaders – clientconsultation; clinicalframeworkSupplemented by broadpanel of external clinicalexperts as consultants (forguidelines) URAC Accreditation & NCQA Certified5Advanced DiagnosticImagingCardiac SolutionsRadiation ical Medicine(Chiropractic Care, SpeechTherapy, Physical andOccupational Therapies)Provider Profiling andPractice ManagementAnalysis
Magellan Healthcare Prior Authorization ProgramProcedures Performed on or after October 1, 2019 Require Prior AuthorizationMagellan Healthcare’s Call Center & RadMD will open September 20, 2019Outpatient/OfficeInpatient and OutpatientInterventional Pain Management (IPM)Lumbar & Cervical Spine SurgerySpine Procedures Spinal Epidural InjectionsParavertebral Facet Joint Injections or BlocksParavertebral Facet Joint Denervation (RadiofrequencyNeurolysis)Sacroiliac Joint InjectionsExcluded from Program-Interventional Pain Management(IPM) Procedures Performed in the Following Settings: Hospital InpatientObservation RoomEmergency Room/Urgent Care Facility Lumbar Microdiscectomy Lumbar Decompression (Laminotomy, Laminectomy,Facetectomy & Foraminotomy) Lumbar Spine Fusion (Arthrodesis) With or WithoutDecompression – 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)Excluded from ProgramSurgeries Performed in the Following Settings: Emergency Surgery – admitted via the Emergency RoomPlease note that CPT Codes 22800-22819 used for reconstructive spinal deformity surgery and the associated instrumentation do notrequire Magellan Healthcare/Gateway Health prior authorization. Magellan Healthcare will monitor the use of these CPT codes, but priorauthorization is not currently required. As long as the deformity surgery does not include CPT codes on Magellan Healthcare/GatewayHealth utilization review matrix/prior authorization list, the claim for the case will process accordingly.6
Magellan Healthcare Prior Authorization ProgramInpatient and OutpatientHip, Knee and Shoulder SurgeryInpatient and Outpatient Hip Surgery : Revision/Conversion Hip Arthroplasty Total Hip Arthroplasty/Resurfacing Femoroacetabular Impingement (FAI) Hip Surgery(includes CAM/pincher & labral repair) Hip Surgery – Other (includes synovectomy, loose bodyremoval, debridement, diagnostic hip arthroscopy, andextra-articular arthroscopy knee)Inpatient and Outpatient Knee Surgery : Revision Knee ArthroplastyTotal Knee Arthroplasty (TKA)Partial-Unicompartmental Knee Arthroplasty (UKA)Knee Manipulation under Anesthesia (MUA)Knee Ligament Reconstruction/RepairKnee Meniscectomy/Meniscal Repair/MeniscalTransplant Knee Surgery – Other (includes synovectomy, loose bodyremoval, diagnostic knee arthroscopy, debridement withor without chondroplasty, lateral release/patellarrealignment, articular cartilage restoration)7Inpatient and Outpatient Shoulder Surgery Revision Shoulder Arthroplasty Total/Reverse Shoulder Arthroplasty or Resurfacing Partial Shoulder Arthroplasty/Hemiarthroplasty Shoulder Rotator Cuff Repair Shoulder Labral Repair Frozen Shoulder Repair/Adhesive Capsulitis Shoulder Surgery – Other (includes debridement,manipulation, decompression, tenotomy, tenodesis,synovectomy, claviculectomy, diagnostic shoulderarthroscopy)Excluded from Program- Hip, Knee & ShoulderSurgeries Performed in the Following Settings:Emergency Surgery – admitted via the Emergency Room
Using Gateway Health’s Network Magellan Healthcare will use the Gateway Health and Gateway HealthMedicare Assured network of Pain Management Physicians, Surgeons,Hospitals, Surgery Centers, and In-Office Providers as it’s preferred providers fordelivering Outpatient Interventional Spine Pain Management Services andselect Inpatient and Outpatient Surgeries to Gateway Health membersthroughout Pennsylvania.8
List of CPT Procedure Codes RequiringPrior Authorization CPT codes and their allowable billablegroupings Defer to Gateway Health plan policiesfor procedures not onclaims/utilization review matrix Located on RadMD.com Review claims/utilization reviewmatrix to determine CPT codesmanaged by Magellan Healthcare9
Responsibility for AuthorizationOrdering ProvidersFacility/Place of ServiceResponsible for obtaining priorauthorizationEnsuring that prior authorization hasbeen obtained prior to providing service10
Prior Authorization Process OverviewAlgorithmSubmit Requests byPhoneOrderingPhysicianClaim11Or Online ThroughRadMDwww.RadMD.comRendering ProviderPerforms ServiceInformation evaluatedvia algorithm andmedical recordsService Authorized
Patient and Clinical Information RequiredInformation for AuthorizationCLINICAL INFORMATIONGENERAL Clinical Diagnosis Physical exam findings and patient symptoms (includingfindings applicable to the requested procedure) Date of onset of pain or exacerbation. Duration ofpatient’s symptoms. For spinal surgeries, only one authorization request persurgery. For example, a Lumbar fusion authorizationincludes decompression, instrumentation, etc.Conservative treatment modalities completed, duration,and results (e.g., physical therapy , chiropractic orosteopathic manipulation, hot pads, massage, ice packsand/or medication) An inpatient hospital stay must be prior authorizedthrough Gateway Health for an approved surgery.Date and results of prior interventional painmanagement procedures, where applicable. Diagnostic imaging results, where applicable. Preliminary procedures already completed (e.g., labwork, scoped procedures, referrals to specialist,specialist evaluation)Includes things like ordering physician information,member information, place of service, requestedprocedure, etc.SPECIAL INFORMATION Every interventional pain management procedureperformed requires a prior authorization; MagellanHealthcare does not pre-approve a series of epiduralinjections. Date of Service is required. Bilateral hip or knee surgeries require two separateauthorizations.1212
Magellan Healthcare Clinical Foundation & ReviewClinical Guidelines Are the FoundationClinical guidelines and algorithms were developed by practicingspecialty physicians, literature reviews, and evidence base.Guidelines are reviewed and mutually approved by GatewayHealth and Magellan Healthcare’s Chief Medical Officers andClinical Specialty Experts.Validation of clinical criteria within the patient’s medical record isrequired before an approval can be made.Clinical Algorithms collect pertinentinformationFax/Upload Clinical Information(upon request)Magellan Healthcare reviews key clinical information to ensurethat Gateway Health members are receiving appropriate care priorto more invasive procedures being performed.Magellan Healthcare has a specialized clinical team focused onmusculoskeletal care. Peer-to-peer discussions are offered forany request that does not meet medical necessity guidelines.Medicaid re-review is allowed for 14 calendar days from the dateof denial by P2P only. You may follow appeal process throughGateway Health defined in the notice of the denial provide to you.Clinical Review by Magellan Healthcare’sSpecialty ExpertsMedicare re-open is NOT allowed.No change in current appeals process.Our goal – ensure that Gateway Health members are receivingappropriate musculoskeletal care.Peer-to-Peer Discussion13Clinical Guidelines available on www.RadMD.com
Magellan Healthcare to Physician: Request for ClinicalInformation A fax is sent to the provider detailingwhat clinical information that is needed,along with a Fax Coversheet We stress the need to provide the clinicalinformation as quickly as possible so wecan make a determination Determination timeframe begins afterreceipt of clinical information Failure to receive requested clinicalinformation may result in noncertification14
Submitting Additional Clinical Information Location of Fax Coversheets: Can be printed fromwww.RadMD.com Call Medicare 1-800-424-1728 Medicaid 1-800-424-4890 Use the case specific faxcoversheets when faxing clinicalinformation to MagellanHealthcare Records may be submitted: Upload to www.RadMD.com Fax using that MagellanHealthcare coversheet15
Clinical Specialty Team: Focused on MSKSpecialized ClinicalClinical Specialty TeamTeamIPM ReviewsMSK SurgeryReviewsInitial clinical reviewperformed by MagellanHealthcare neurologyteam nurses16The clinical specialtiessupporting our IPMprogram includeanesthesiology,orthopedic spine surgery,neurology, neurosurgery,and pain specialistsSurgery conciergeteam willproactivelyoutreach foradditionalinformation,reconsiderationsand to schedulepeer-to-peersession.Nurses willassemble surgerycases and reach outfor clinicalinformation asneeded prior tosending to surgeonreviewers.Only orthopedicsurgeons orneurosurgeonsconduct clinicalreviews and peerto-peer discussionon surgeryrequests.
Notification of DeterminationAuthorization NotificationDenial Notification Authorizations DenialsValidity Period - Authorizations are validfor: IPM 60 days from Date of Service /Request Surgical Inpatient – 60 days from Dateof Service / Request* Outpatient- SDC/Ambulatory –60 days from Date of Service /Request You may ask Magellan Healthcarefor a reconsideration of ourdecision with additionalinformation. You may also followthe appeal process throughGateway Health defined in thenotice of denial provided to you.*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 DOSchanges please contact Magellan Healthcare to update.17
Magellan Healthcare Urgent/ExpeditedAuthorization ProcessUrgent/Expedited Authorization ProcessIf an urgent clinical situation exists (outside of a hospital emergency room),please call Magellan Healthcare immediately. The number to call to obtain a priorauthorization is: Medicaid: 1-800-424-4890 Medicare: 1-800-424-172818
Summary Interventional Pain Management(IPM) Points Injections in all regions of spine are managed Date of Service is required for all requests Each IPM procedure must be prior authorized No series of epidural injections Specialty Nurses and Physicians will review IPM requests19 19
Summary Musculoskeletal Surgery PointsLumbar/Cervical Spine Surgery 20 20Inpatient and outpatient non-emergentsurgeriesSpine Surgery is focused on lumbar and/orcervical spine surgeriesFor spinal surgeries, only one authorizationrequest per surgery. For example, a Lumbarfusion authorization includes decompression,instrumentation, etc.CPT Codes 22800-22819 used forreconstructive spinal deformity surgery andthe associated instrumentation do not requireprior authorization. Magellan Healthcare willmonitor the use of these CPT codes. As long asthe deformity surgery does not include CPTcodes on Magellan Healthcare/Gateway HealthUtilization Review Matrix and PriorAuthorization list, the claim for the case willprocess accordinglyHip, Knee and Shoulder Surgery Bilateral hip or knee surgeries require twoseparate authorizationsSurgeries addressing the following are notincluded in the musculoskeletal managementprogram: trauma, amputation, fracture, activeinfection, pediatric conditions, congenitalmalformation, dysplasia (hip), palsy/plegia,osteochondritis dissecans (knee), osteotomy(knee), tumor, cyst, cancer, arthrodesis, girdleresection (hip), denervation (hip), jointdislocation, hemiarthroplasty (hip), & foreignbody
Summary Musculoskeletal Surgery PointsContinued For all surgeries Specialized Orthopedic Surgeons or Neurosurgeons will review surgery requests. Any Gateway Health Medicare Assured or Medicaid prior authorizationrequirements for the facility or hospital admission must be obtained separately andonly initiated after the surgery has met Magellan Healthcare’s medical necessitycriteria. Authorizations are valid for 60 days from the date of service or if no date of service isavailable, then from date of request. Magellan Healthcare must be notified of anychanges to the date of service.21 21
Provider Tools Toll free authorization and information number: 1-800-424-4890 (Medicaid) 1-800-424-1728 (Medicare – PA)Available 8:00 a.m. – 8:00 p.m. EST Interactive Voice Response (IVR) System forauthorization tracking RadMD Website, www.RadMD.com – Available 24/7 (exceptduring maintenance) Request Authorization View Authorization Status Upload Additional Clinical Information View Clinical Guidelines View Frequently Asked Questions (FAQs) View Other Educational Documents22
Magellan Healthcare's Websitewww.RadMD.comRadMD Functionality varies by user: Rendering Provider – Views approvedauthorizations for their facility. Ordering Provider’s Office – View and submitrequests for authorization.Online Tools Accessed through www.RadMD.com: Magellan Healthcare’s Clinical Guidelines Frequently Asked Questions Quick Reference Guides RadMD Quick Start Guide Claims/Utilization Matrices23
Ordering Provider: Getting Started on RadMD.com(MSK)Everyone in your organization is required to havetheir own separate user name 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 in orderfor our Webmaster to respond to you withyour Magellan Healthcare-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.2423
Rendering Provider: Getting Started on RadMD.com(MSK)IMPORTANT Everyone in your organization is required to have theirown separate user name and password due to HIPAAregulations.1 Designate an “Administrator” for the facility whomanages the access for the entire facility.STEPS:1.Click the “New User” button on the right side of the home page.2.Select “Facility/office where procedures are performed”3.Fill out the application and click the “Submit” button. You must include your e-mail address in order for ourWebmaster to respond to you with your MagellanHealthcare-approved user name and password.NOTE: On subsequent visits to the site, click the “Sign In”button to proceed.If you have multiple staff members entering authorizationsand you want each person to be able to see all approvedauthorizations, they will need to register for a renderingusername and password. The administrator will have theability to approve rendering access for each employee. Thiswill allow users to see all approved authorizations under yourorganization.2523
When to Contact Magellan Healthcare:Providers: To initiate a request for an authorization: please contact Magellan Healthcare via website,www.RadMD.com or via toll-free number 1-800-424-4890 (Medicaid) 1-800-424-1728 (Medicare – PA) To check the status of an authorization: please contact Magellan Healthcare via website,www.RadMD.com or Interactive Voice Response (IVR) System 1-800-424-4890 (Medicaid) 1-800-424-1728 (Medicare – PA) For assistance or questions directed to Magellan Healthcare: call the Provider Service Line at1-800-327-0641. For assistance or technical support for RadMD: please contact RadMD Help Desk via e-mailRadMDSupport@magellanhealth.com or 877-80-RadMD (877-807-2363). For any provider education requests or questions specific to Magellan Healthcare and thePhysical Medicine, and MSK Program, please contact: Justin Clifford PT, DPTLori FinkSr. Provider Relations ManagerProvider Relations health.com1-800-450-7281, ext. 557211-800-450-7281, ext. 7533526
RadMD Demonstration27
Confidentiality StatementThe information presented in this presentation is confidential and expected to be used solely in support of thedelivery of services to Gateway Health and Gateway Health Medicare Assured members. By receipt of thispresentation, each recipient agrees that the information contained herein will be kept confidential and that theinformation will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the priorwritten consent of Gateway Health and Gateway Health Medicare Assured and Magellan Healthcare, Inc.28
Questions?
Any Gateway Health Medicare Assured or Medicaid prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery has met Magellan Healthcare's medical necessity criteria. Authorizations are valid for 60 days from the date of service or if no date of service is
