WIXLIB

Gateway HealthSM Medicare andGateway HealthSM Medicaid(Gateway Health)Physical Medicine ProgramProvider Training

Magellan Healthcare1 Physical Medicine Program AgendaOur ProgramPrior Authorization Process and Overview Clinical Information Required Subsequent Requests Peer to Peer Review Notification of Determination ClaimsProvider Tools and Contact InformationRadMD DemoQuestions and Answers1National2Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc.

Magellan Healthcare Medical Specialty SolutionsNational Footprint / Medicaid ghtsNational FootprintProviding Client Solutions since1995 – one of the go-to care partners inindustry.12.35M Medicaid lives – in addition to 3.9MExchange and 2M Medicare Advantage livesparticipating in a medical specialty solutionsprogram nationally.64 health plans/markets – partneringwith Magellan Healthcare for themanagement of medical specialtysolutions.28.02M national lives – participatingin a medical specialty solutions program.Diverse populations – Medicaid,Exchanges, Medicare, Commercial, FEP,Provider Entities.Physical Medicine MedicaidExperience3.5M Physical Medicine Medicaid livesIntensive ClinicalSpecialization & BreadthSpecialized Physician Teams 160 actively practicing, licensed, boardcertified physicians 28 specialties and sub-specialtiesURAC Accreditation & NCQA Certified3

Magellan Healthcare’s Physical MedicinePrior Authorization ProgramImportant DatesThe Program 4Gateway Healthbegan a priorauthorizationprogram throughMagellan Healthcarefor the managementof Physical MedicineServices.The program includesboth rehabilitativeand habilitative care. Program startdate was:October 1, 2019Disciplines &Settings IncludedDisciplines: Physical Therapy Occupational Therapy Speech TherapySettings: Outpatient Office Outpatient Hospital Home HealthMembershipIncluded MedicaidMedicare

Magellan Healthcare’s Physical Medicine SolutionGateway Health’s network of Physical Medicine providers includingtherapists and facilities will be used for the Physical Medicine ProgramTargeted Physical MedicineProcedures Performed in anOutpatient/Office/Home HealthSetting: Physical Therapy Speech Therapy Occupational TherapyExcluded from the Program PhysicalMedicine Procedures Performed in thefollowing Settings: Hospital EmergencyDepartment Hospital status inpatient orobservation Acute Rehab Hospital(Inpatient) Skilled Nursing (POS 31 &32)The program applies when members have Gateway Health as the primaryor secondary insurer.5

Initial Authorization Process OverviewAlgorithmPrior AuthorizationProcessAfter the evaluation hasbeen completed*and/or a plan of careestablished, requestauthorization for theservices/codes to berenderedClaims submitted,match to authorization& pay accordinglyLog in towww.RadMD.com orcall MagellanHealthcare’s CallCenter prior to ORwithin 5 businessdays of rendering ionSubmitted, Reviewedand Decision Rendered*PT, OT and ST Initial evaluation CPT codes do not require authorization.6ClinicalAlgorithmTreatment maybe authorizedand/or you maybe instructed tosubmit clinicaldocumentationfor validationupon completionof the evaluation.

Magellan Healthcare’s Clinical Foundation & ReviewClinical Guidelines Are the FoundationClinical Algorithms collect pertinentinformationFax/Upload Clinical Information(upon request)Clinical Review by Magellan Healthcare’sSpecialty CliniciansPeer-to-Peer Discussion7 Magellan Healthcare clinical guidelines arereviewed and mutually approved by GatewayHealth and Magellan Healthcare’s Chief MedicalOfficers and senior clinical leadership Milliman Care Guidelines (MCG) LicensedGuidelines for physical medicine services Magellan Healthcare’s Clinical Guidelines areavailable on www.RadMD.com Algorithms are a branching structure that changesdepending upon the answer to each question. The member’s clinical information/medical recordwill be required for validation of clinical criteriabefore an approval can be made. Magellan Healthcare has a specialized clinicalteam focused on Physical Medicine. Peer-to-peer discussions are offered for anyrequest that does not meet medical necessityguidelines. Our goal – ensure that members arereceiving appropriate care.

Understanding the Goal of the Physical MedicineIntake Questions (Algorithm)Benefit of the algorithm No delay in treatment for member No delay in submitting claimsOnce you submit your initial request forauthorization, you will receive visits to getyou started While the majority of the authorizationsmay be approved at the time ofsubmission, a portion of them may pendfor documentation submission at thetime of entry. You will have the option to accept ordecline approved visits.Additional visits may be approved onceclinical documentation has been submittedwith subsequent requests process8

Member and Clinical Information Required forAuthorizationGeneral Information: Member, clinician, and facilityinformation.Clinical Information at Intake: Requested start date ofservice, initial evaluation date, and date of injury.Clinical Record Content: Therapy initial evaluation,diagnosis, functional status (prior & current), functionaldeficits, objective tests and measures, standardizedoutcome tools (at your clinician’s discretion), plan of care(including frequency, duration, interventions planned &goals*), assessment (prognosis & limitations).* Goals should be specific, measurable, and time-oriented, as well as targeting identified functional deficits.Refer to the “Provider Tip Sheet/Checklist” on www.RadMD.com for more specific information.9

Clinical Records ChecklistThe Following Documentation is Required for Authorization RequestsRehabilitative CasesInitial Evaluation0-9Visits10 Visits or greaterthan 30 DaysXXInclude if not part of initial submissionXXPlease send updated outcome measures with the progressnote and/or at appropriate timesXXAfter IE, please send 2 most recentCommentsOutcome MeasureDaily NoteProgress NoteXHabilitative Cases0 - 30DaysInitialEvaluationStandardizedTestingDaily NotesProgress NotesRe-evaluation1030 - 90Days3 - 11Months12 Monthsor GreaterCommentsInclude if not part of initial submissionXXXXXXXXXXXXXXUpdated at least once yearlyConsider a different test if deficits not shown on originaltestAfter IE, please send 2 most recent

Magellan Healthcare to Physician:Request for Clinical InformationA fax is sent to the provider detailingwhat clinical information that isneeded, along with a Fax CoversheetWe stress the need to provide theclinical information as quickly aspossible so we can make adeterminationDetermination timeframe beginsafter receipt of clinical informationFailure to receive requested clinicalinformation may result in noncertification11

Submitting Additional Clinical Information Records may be submitted: Upload to www.RadMD.com Fax using that MagellanHealthcare coversheet 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 MagellanHealthcare12

Magellan Healthcare Physical Medicine Program:UM/Prior Auth ProcessTelephoneRadMDProvider contactsMagellan Healthcare forprior authorizationfollowing the initialevaluation.Clinical algorithmevaluates request basedon information entered byprovider to determine ifreal-time authorization isappropriate for initialrequest.Clinical informationcomplete ServicesApproved?Additional clinicalinformation requiredCase is pended forclinical records.Outreach toprovider fornecessary clinicalinformation. You will receive aTracking Number:123456789Magellan Healthcare PeerClinical Review. Ifinformation captured inintake algorithm isinsufficient to supportautomatic approval ofservices, clinical records mustbe submitted for review.Services appearappropriate Approved You will receive anapprovedAuthorizationNumber/Case IDNumber:12345ABC1234Services notsupported asmedically necessary AdverseDeterminationGenerally the turnaround time for completion of these requests is within two business days upon receipt ofsufficient clinical information13Determination andNotificationAuthorization of a setof visits and a validityperiod. Notificationssent to member,provider, and orderingphysician whenmandated by state.Clinical information doesnot support the requestedservices as medicallynecessary.A peer-to-peer reviewis always availableNotification of finaldetermination is sent tomember, provider andordering physician whenmandated by state.

Initiating a Subsequent RequestWhen is asubsequent requestappropriate?How aresubsequentrequests initiated?When can it beinitiated?Will I lose visits?14 When you have an active authorizationA need for continued careA change in the treatment plan or plan of careThe addition of a new diagnosis Through the link on RadMD Faxing updated clinical documentation Can be initiated at any time after receivingnotification about the previous authorization Visits build on the original authorization Visits from a current authorization will not be lost andnewly approved visits will be added to the originalauthorization

Treating an Additional Body PartIf a provider is in the middle of treatment and gets a new therapy prescription for a differentbody part, the provider will perform a new evaluation on that body part and develop goalsfor treatment. See below for processes associated with the possible next treatment plans:15Treating body partsconcurrently:Discontinuing care onoriginal body part: The request would besubmitted as an addendumto the existingauthorization, using thesame process that is usedfor subsequent requests. Magellan Healthcare willadd additional ICD 10code(s) and visits to theexisting authorization. The provider should submita new request for the newdiagnosis and include thedischarge summary for theprevious area. A newauthorization will beprocessed to begin care onthe new body part and theprevious will be ended.

Validity Period and Notification of DeterminationAuthorization Notification The approval notification will include afax coversheet that can be used for anysubsequent requests.Validity Period 16Authorizations will include the number ofapproved visits with a validity period. It isimportant that the service is performedwithin the validity period.If you have an active authorization, a 30day extension of the validity period canbe obtained by contacting MagellanHealthcare.Denial Notification Notifications will include an explanation of whatservices have been denied and the clinicalrationale for the denial A peer to peer discussion can be initiated oncethe adverse determination has been made. A re-review is available with new or additionalinformation. Timeframe for re-review is 14 days from thedenial by peer to peer only. Medicare re-opens are not available. In the event of a denial, providers are asked tofollow the appeal instructions provided in theirdenial letter.

Processing of ClaimsHow Claims Should be SubmittedClaims Appeals Process Providers will continue tosubmit their claims to GatewayHealth In the event of a prior authorization Providers are stronglyencouraged to use EDI claimssubmission17or claims payment denial, providersmay appeal the decision throughGateway Health Providers should follow theinstructions on their nonauthorization letter or Explanationof Payment (EOP) notification