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Radiology Prior Authorization forPriority HealthProvider Orientation 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

100M MembersManagedNationwide9ComprehensiveSolutionsThe industry’s mostcomprehensive clinicalevidence-based guidelines4k employees including1k cliniciansHeadquartered in Bluffton, SCOffices across the US including: Lexington, MA Colorado Springs, CO Franklin, TN Greenwich, CT eviCore healthcare. All Rights Reserved.This presentation contains CONFIDENTIAL and PROPRIETARY information.Melbourne, FLPlainville, CTSacramento, CAEngaging with 570k providersAdvanced, innovative, andintelligent technology2

lutionsEnd-to-End SolutionIntegrated platformSleep ManagementMedical OncologySpecialty DrugRadiation TherapyLab ManagementPost-Acute Care eviCore healthcare. All Rights Reserved.This presentation contains CONFIDENTIAL and PROPRIETARY information.3

Radiology Solution - Our Experience30 Regional570k 24 Yearsand National Clientsproviders engagedManaging Radiology Services69M membersmanaged nationwideMembers Managed 51M CommercialMemberships 6.8M Medicare Memberships 7.2 Medicaid Memberships4

Our Clinical Approach5

Clinical PlatformMulti-Specialty Expertise Family MedicineOncology/HematologyInternal MedicineSurgeryPediatricsSports MedicineOB/GYNCardiology yngologySpineNuclear MedicineRadiologyAnesthesiologyRadiation OncologySleep Medicine Nuclear MedicineMusculoskeletalNeuroradiology260 board-certified medicaldirectors Diverse representation of medicalspecialties 800 nurses with diversespecialties and experience Dedicated nursing and physicianteams by specialty for Radiology,Cardiology, Oncology, OB-GYN,Spine/Orthopedics, Neurology,and Medical/Surgical6

Evidence-Based GuidelinesThe foundation of our sfrom a panelof communityphysiciansExpertsassociatedwith ed with National Societies American College of Cardiology American Heart Association American Society of Nuclear Cardiology Heart Rhythm Society American College of Radiology American Academy of Neurology American College of Chest Physicians American College of Rheumatology American Academy of Sleep Medicine American Urological Association National Comprehensive Cancer Network American College of Therapeutic Radiology andOncology American Society for Radiation Oncology American Society of Clinical Oncology American Academy of Pediatrics American Society of Colon and Rectal Surgeons American Academy of Orthopedic Surgeons North American Spine Society American Association of Neurological Surgeons American College of Obstetricians andGynecologists The Society of Maternal-Fetal Medicine7

Service Model8

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.9

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.10

Radiology Prior AuthorizationProgramfor Priority Health11

Program OvervieweviCore will begin accepting requests on September 5, 2018Prior authorization appliesto services that are: Outpatient Elective / Non-emergent DiagnosticPrior authorizationdoes not apply to servicesthat are performed in: Emergency room 23-hour observation InpatientIt is the responsibility of the ordering provider to request prior authorization approval forservices.12

Applicable MembershipAuthorization is required for Priority Health members enrolled in the followingprograms: Commercial members Medicaid members Medicare members13

Prior Authorization Required: CT, CTA (Computed Tomography,Computed Tomography Angiography) MRI, MRA (Magnetic Resonance Imaging,Magnetic Resonance Angiography) PET, PET/CT (Positron EmissionTomography, PET with ComputedTomography) To find a list of CPT(Current Procedural Terminology)codes that require prior authorizationthrough eviCore, please ealthNuclear Medicine14

Prior Authorization RequestsHow to request prior vider*Available 24/7 and the quickest way tocreate prior authorizations and checkexisting case status. Log into yourprovider account at priorityhealth.comand click “Auth Request” to accesssystem.*Users must log in via priorityhealth.com and cannotenter the Priority Health program via eviCore.comPhone Option: 844.303.8456 7:00 a.m. to 7:00 p.m. (EST) Monday - FridayFax option: 800.540.2406 Fax forms available atwww.evicore.com/healthplan/priorityhealth15

Needed InformationMemberMember IDMember nameDate of birth(DOB)Rendering FacilityFacility nameNational provider identifier(NPI)Tax identification number (TIN)Street addressReferring PhysicianPhysician nameNational provider identifier(NPI)Tax identification number (TIN)Fax numberSupporting ClinicalPatient’s clinical presentation.Diagnosis Codes.Disease-Specific Clinical Information.Patient’s intended treatment planIf clinical information is needed, please be able to supply: Prior tests, lab work, and/or imaging studies performed related to this diagnosisThe notes from the patient’s last visit related to the diagnosisType and duration of treatment performed to date for the diagnosis16

Prior Authorization OutcomesApproved Requests: Delivery:Denied Requests:Delivery:Delivery:Medicare: the program will render a decision within 2business days after receipt of all clinical information.Authorizations are good for 90 days from the date ofdetermination. Faxed to ordering provider and facilityMailed to the memberInformation can be printed by logging into eviCorefrom your priorityhealth.com account. Communication of denial determinationCommunication of the rationale for the denialHow to request a Clinical Consultation Faxed to the ordering providerMailed to the member17

Prior Authorization Outcomes – Commercial and MedicaidReconsiderations Clinical Consultations Peer-to-Peer Review Additional clinical information can be providedwithout the need for a physician to participateMust be requested within 14 business daysfollowing the date of the determinationCommercial and Medicaid members onlyIf a request is denied and requires further clinicaldiscussion for approval, we welcome requests forclinical determination discussions from referringphysicians.Clinical Consultations must be requested within 14business days following the date of thedetermination.In certain instances, additional information providedduring the consultation is sufficient to satisfy themedical necessity criteria for approval.Clinical Consultation reviews can be scheduled at atime convenient to your physician with a same18specialty expertise Medical Director.

Prior Authorization Outcomes – Medicare / Medicare AdvantagePre-Decision Consultation If your case requires further clinical discussion for approval, we welcomerequests for clinical determination discussions from referring physiciansprior to a decision being rendered. In certain instances, additional information provided during the predecision consultation is sufficient to satisfy the medical necessity criteriafor approval19

Special Circumstances Appeals Retrospective Studies: Outpatient UrgentStudies: eviCore will process first level provider authorizationappeals for Commercial membership onlyRequests for appeals must be submitted in writing toeviCore within 120 calendar days of the initialdeterminationThe procedure request and all clinical informationprovided will be reviewed by a physician other than theone who made the initial determination.A written notice of the appeal decision will be mailed tothe member and faxed to the providerMedicare does not allow retro authorization requests.Retro Requests must be submitted with 120 calendar daysfor Commercial members and within 30 calendar daysfor Medicaid members following the date of service.Requests submitted later than these dates will beadministratively denied.Retro requests are reviewed for clinical urgency andmedical necessity. The Program will render a decision on aretrospective request within 30 calendar days of theretrospective request.Medically urgent requests are defined as conditionsthat are a risk to the patient’s life, health, ability toregain maximum function, or the patient is havingsevere pain that required a medically urgentprocedure.Contact eviCore by phone to request an expedited priorauthorization review and provide clinical informationUrgent Cases will be reviewed within 24 hours forMedicare and Medicaid membership and within 72hours for Commercial membership of the request. 20

Requesting an AuthorizationWeb Portal Services21

Initiating A Case22Go to provider portal log in screen at http://www.priorityhealth.com/provider.

Initiating A CaseEnter user name and password then click “Login”23

Initiating A CaseClick on “Request an authorization”24

Initiating A CaseReferring practice must select either “Hospital” or “Practitioner or Vendor.”25

Initiating A CaseUsing drop-down boxes, referring physician must select procedure/CPT codeand facility. Then click “Go to eviCore.” and26

Service OptionsChoose “Request a clinical certification/procedure” to begin a new case request.27

Select ProgramHigh Tech ImagingSpine and JointGenetic TestingSelect the Program for your certification.28

Select Referring ProviderSelect the Practitioner/Group for whom you want to build a case.29

Referring Provider Contact InformationEnter the appropriate information for the point of contact individual.30

Member/Procedure InformationVerify if the procedure has already been performed.31

Member InformationEnter the member information including the Patient ID number, date of birth, andpatient’s last name. Click “Eligibility Lookup.”32

Member InformationConfirm member information including the address. Click “Select”.33

Member InformationEnter the member’s best contact number.34

Clinical DetailsSelect the CPT and Diagnosis codes.35

Verify Service SelectionClick continue to confirm your selection.36

Site Selection for Rendering PhysicianVerify all information entered and make any needed changes prior to movinginto the clinical collection phase of the prior authorization process. The referringphysician information appears at the left screen, and you will select therendering physician and site.37You will not have the opportunity to make changes after that point.

Site Selection Setting for Rendering PhysicianSelect what setting the procedure will be performed.38

Clinical CertificationClick “Continue” to begin entering the clinical information.39

Clinical CertificationQuestions will populate based upon the information provided.40

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.41

Medical ReviewAcknowledge the Clinical Certification statements, and hit “Submit Case.”42

ApprovalOnce the clinical pathwayquestions are completedand if the answers havemet the clinical criteria, anapproval will be issued.Print the screen and storein the patient’s file.43

Building Additional Cases44