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Gateway Health & GatewayHealth Medicare Assured(Gateway Health)Medical Specialty Solutions

Magellan Healthcare Program AgendaIntroduction to Magellan HealthcareOur Program Authorization Process Other Program Components Provider Tools and Contact InformationRadMD DemoQuestions and Answers2

Magellan Healthcare SpecialtyNational Footprint / Medicaid ghtsNational FootprintSince 1995 – delivering radiologybenefits management solutions; one ofthe go-to care partners in industry.42 Medicaid plans/markets with MagellanHealthcare RBM solutions in place.Uniquely independent – only major12.5M Medicaid lives – in addition to 3.9Mspecialty company not aligned to healthplan ownership.Exchange and 2M Medicare Advantage livesparticipating in a Magellan Healthcare RBMprogram nationally.64 health plans/markets – partneringwith Magellan Healthcare formanagement of advanced and/or cardiacimaging solutions.28M national lives – participating ina Magellan Healthcare RBM nationally.14M Commercial livesIntensive ClinicalSpecialization & BreadthSpecialized Physician Teams 160 actively practicing, licensed, boardcertified physicians 28 specialties and sub-specialtiesDiverse populations – Medicaid,Exchanges, Medicare, Commercial, FEP,Provider Entities.URAC Accreditation & NCQA Certified3

Magellan Healthcare’s Prior Authorization ProgramProcedures &Settings IncludedThe Program Gateway Health begana prior authorizationprogram throughMagellan Healthcarefor the management ofOutpatient DiagnosticImaging, PhysicalMedicine*,Interventional PainManagement*,Inpatient andOutpatientMusculoskeletalSurgeries*Procedures: CT/CTA MRI/MRA PET Scan CCTA MPI Stress Echo IPM* Inpatient andOutpatientMusculoskeletalMembershipIncluded MedicaidMedicareNetwork Magellan Healthcarewill use the GatewayHealth network of Inoffice providers, FreeStanding ImagingFacilities (FSF’s), andHospitals to deliveroutpatient imagingservices to GatewayHealth Medicare andGateway HealthMedicaid members. Surgeries* Physical Medicine *Settings:4 Office Outpatient Hospital Inpatient Hospital (MSK)* Please see specific educational documents on RadMD for each Medical Specialty Solutions Program Services

Magellan Healthcare’s Prior Authorization ProgramOnly non-emergent procedures performed in an outpatient setting requireauthorization with Magellan Healthcare.Procedures RequiringAuthorization CT/CTAMRI/MRAPET ScanMUGACCTAMyocardial PerfusionImaging Stress Echocardiography5Excluded from the ProgramProcedures Performed in thefollowing Settings: Hospital Inpatient Observation Emergency Room

List of CPT Procedure Codes Requiring Prior AuthorizationReview Claims/Utilization ReviewMatrix to determine CPT codesmanaged by MagellanHealthcare.CPT Codes and their AllowableBillable Groupings.Located on www.RadMD.com.Defer to Gateway Health’sPolicies for Procedures not onClaims/Utilization Review Matrix.6

Prior Authorization Process OverviewAlgorithmSubmit RequestsOnline ThroughRadMDwww.RadMD.comOrdering Physician isresponsible for obtainingprior authorization.Information evaluatedvia algorithm andmedical recordsor by PhoneRendering ProviderPerforms Service andensures authorizationwas obtainedService AuthorizedRecommendation to Rendering Providers: Do not schedule test until authorization is received7

Magellan Healthcare’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 andMagellan Healthcare Medical Officers andclinical experts. Clinical Guidelines are availableon 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. Magellan Healthcare has a specialized clinicalteam. Peer-to-peer discussions are offered for anyrequest that does not meet medical necessityguidelines. Our goal – ensure that members arereceiving appropriate care.Clinical Algorithms collect pertinentinformationFax/Upload Clinical Information(upon request)Clinical Review by Magellan Healthcare’sSpecialty 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 ReviewMagellan Healthcare may requestmember’s medical records/additionalclinical information.When requested, validation of clinicalcriteria within the member’s medicalrecords is required before an approvalcan be made.Ensures that clinical criteria thatsupports the requested test are clearlydocumented in medical records.Helps ensure that members receivethe most appropriate, effective care.11

Magellan Healthcare to Ordering Physician:Request for Additional Clinical InformationA 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.12

Submitting Additional Clinical Information Records may be submitted: Upload to www.RadMD.com Fax using that Magellan Healthcarecoversheet Location of Fax Coversheets: Can be printed from www.RadMD.com Call:Medicaid: 1-800-424-4890Medicare 1-800-424-1728 Use the case specific fax coversheets whenfaxing clinical information to MagellanHealthcare13

Clinical Review ProcessMagellan Healthcare InitialClinical Specialty Team ReviewPhysicians’ Office Contacts MagellanHealthcare 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 Physician4Magellan Healthcare SpecialtyPhysician Reviewers Magellan Healthcare Physician approves casewithout peer to peer Clinical information complete – Procedure Approved Additional clinical information required – Pends forclinical validation of medical recordsKey MagellanHealthcareDifferentiatorsPeer-to-peer outbound attemptmade if case is not approvable Magellan Healthcare Physician approves casewith peer to peer Ordering Physician withdraws case during peerto peer Physician denies case based on medical criteriaGenerally the turnaroundfor receivecompletionof theserequests is withintwo to 24threebusinessdays upon receipt of92% oftimecasesfinaldeterminationswithin– 48hourssufficient clinical information14

Magellan Healthcare Urgent/ExpeditedAuthorization ProcessUrgent/Expedited Authorization Process If an urgent clinical situation exists (outside of a hospital emergency room)during business hours, please call Magellan Healthcare immediately. The Magellan Healthcare Website www.RadMD.com cannot be used formedically urgent or expedited prior authorization requests during businesshours. Those requests must be processed by calling the Magellan Healthcarecall centerMedicaid: 1-800-424-4890Medicare 1-800-424-172815

Notification of DeterminationAuthorization Notification Validity Period - Authorizations arevalid for: 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. Medicaid: re-review is available with newor additional information within 30calendar days from the date of denial60 days from request date Medicare re-open is NOT allowed. 16In the event of a denial, providers are askedto follow the appeal instructions providedin their denial letter.

Claims and AppealsHow Claims Should be Submitted Rendering providers/Imagingproviders should continue tosend their claims directly toGateway Health. Providers are stronglyencouraged to use EDI claimssubmission. Check on claims status by loggingon to the Gateway Healthwebsite ms Appeals Process In the event of a priorauthorization or claimspayment denial, providers mayappeal the decision throughGateway Health Providers should follow theinstructions on their nonauthorization letter orExplanation of Payment (EOP)notification.

Radiation Safety and AwarenessStudies suggest a significant increasein cancer in dose estimates in excessof 50 mSvU.S. population exposed to nearly sixtimes more radiation from medicaldevices than in 1980CT scans and nuclear studies are thelargest contributors to increasedmedical radiation exposureMagellan Healthcare has developed a Radiation Awareness Programdesigned to create member and physician awareness of radiationconcerns18

Provider ToolsRadMD Websitewww.RadMD.comAvailable24/7 (except duringmaintenance)Toll Free NumberMedicaid 1-800-424-4890Medicare 1-800-424-1728 1-800-424-1732Available8:00 AM – 8:00 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 Clinical Guidelines View Frequently Asked Questions (FAQs) View Other Educational Documents Interactive Voice Response (IVR) Systemfor authorization tracking

Magellan Healthcare’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: Magellan Healthcare’s ClinicalGuidelines Frequently Asked Questions Quick Reference Guides Checklist RadMD Quick Start Guide Claims/Utilization Matrices20

Registering on RadMD.comTo Initiate AuthorizationsEveryone 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.2123