HUSKY Health Program and Charter Oak Health Plan Radiology Benefits Management Program

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1 HUSKY Health Program and Charter Oak Health Plan Radiology Benefits Management Program

2 Training Agenda Presentation Overview Introduction of Presenters Radiology Benefits Management Program Overview Prior Authorization Requirements Prior Authorization Process CAREPortal Claims Submission Web Resources 1

3 Training Goals Fully understand the Radiology Benefit Management Program Provide you with information to help navigate through the prior authorization process for advanced imaging modalities Familiarize you with the on-line authorization system Offer sufficient means of research & educational material for future use Presentation will be available online: 2

4 Radiology Benefits Management Program Overview Purpose: Designed to enhance quality of services delivered to patients and reduce unnecessary costs associated with advanced diagnostic imaging Best Practice: Uses evidence-based clinical criteria to promote right test at right time Focus on necessity of requested procedures, where emphasis is put on patients health and treatment options Safety: Utilization and quality components employed in the program focus to minimize patient risk of receiving unnecessary radiation Program designed to be collaborative by offering physicians the opportunity to consult with a radiologist or nuclear cardiologist reviewer at any point during the prior authorization process 3

5 Radiology Benefits Management Program Overview Utilization management services including prior authorization of: MRI/MRA CT/CTA PET PET/CT Nuclear Cardiology studies Complete list of CPT codes requiring prior authorization is available online at Listed Under Provider Documents 4

6 Prior Authorization Requirements Care to Care is prepared to accept requests beginning May 1, 2012 For dates of service June 1, 2012 and forward, advanced imaging and nuclear cardiology procedures will require prior authorization Ordering/Referring CMAP providers are required to obtain prior authorization (Providers not currently enrolled with CMAP will be required to enroll) Ordering CMAP providers can request via: Call Center Phone: (800) Monday through Friday, 8 a.m. to 7 p.m. Fax: (888) Web: or 5

7 Prior Authorization Requirements Prior authorization is required for the following services when performed in free standing diagnostic imaging facilities, provider offices or outpatient hospital settings: MRI/MRA CT/CTA PET, PET/CT Nuclear Cardiology studies Authorization is NOT required if services are provided as part of: Hospital inpatient stay Emergency Room visit Intra-operative procedure 6

8 Prior Authorization Process 3 STEPS Intake Processing Determination Approved Phone Fax Web Peer-to-Peer Reviews Approved at Intake Review Modified/ Withdrawn/ Denied 7

9 Prior Authorization Process Authorization via Call Center-In-Take Specialist Authorization via Fax using Prior Authorization Form Authorization via CAREPortal (on-line web tool) Referring CMAP Physicians utilizing the CAREPortal to submit prior authorizations can access through Husky Health and Charter Oak website Urgent Requests via Phone, Fax, & Web We encourage providers to submit expedited and urgent requests via phone If faxed, providers should indicate URGENT on fax form Urgent requests processed within three (3) hours 8

10 Prior Authorization Form 9

11 Prior Authorization Form 10

12 Prior Authorization Form 11

13 Prior Authorization Form 12

14 Prior Authorization Form 13

15 Prior Authorization Form 14

16 Prior Authorization Form 15

17 Prior Authorization Form 16

18 Prior Authorization Form 17

19 Required Information for Prior Authorization Processing Important: Provider/office staff should have information available at time of request Member Data Member ID Patient name Date of birth CMAP Provider Data Name Specialty Address Telephone and fax number TIN and NPI and Medicaid Provider # Rendering facility name, address, and contact information (if available) 18

20 Required Information for Prior Authorization Processing For providers billing in a professional claim format: (provider offices and independent radiology centers) The service must be requested with CPT code, number of units and modifier if appropriate (bilateral studies) Authorization is not required for professional component modifier 26 For providers billing in an institutional claim format: (outpatient hospitals) Revenue Codes 35X, 404, 61X will always require authorization Revenue Code 34X with any of the CPT codes will always require authorization Revenue Code 34X with any other CPT codes will not require authorization The examination is requested with CPT code and number of units 19

21 Required Information for Prior Authorization Processing Clinical Data A brief summary of clinical indications for services requested with ICD-9 code(s) Major complaints or symptoms What the ordering/referring CMAP provider is looking to rule out Results of prior tests or imaging procedures Outcome of prior treatment, including type and duration, for the same medical indication Office notes relevant to the study requested may be submitted Other relevant information 20

22 Determinations Process Determinations: Typically made within 2 business days Determinations on requests submitted via phone are usually turned around in <10 minutes when all information is provided Authorization Number is issued upon determination Authorizations are valid for 30 days Determination Notices: Will be faxed to the ordering/referring CMAP Provider Will be mailed to the member Will include appeals information in the case of a denial 21

23 Consultation Process Peer to Peer Consultation: Ordering/Referring CMAP Provider may schedule a call with a Board Certified Radiologist or Board Certified Nuclear Cardiologist reviewer at any point when they are ordering a study 22

24 Modification Process Modifications to an authorization: If an authorized study is changed to another requiring prior authorization, a new authorization must be obtained Original authorization will be cancelled 23

25 Appeal Process Appeals: CMAP Provider may appeal a denial verbally or in writing; appeal procedures are provided in the Notice of Action/Denial Letter Care to Care will process appeals regarding medical necessity Level 1 Medical Necessity and Administrative appeals must be initiated within 7 calendar days of receipt of the denial notice. This includes verbal notification Level 2 Medical Necessity appeals must be initiated in writing within 14 calendar days after the first level appeal denial Provider questions related to denied claims will be handled by HP 24

26 CAREPortal Registration Process Access CAREPortal through the following link: Establishing User Names: Multiple usernames/passwords can be provided for individual facility Each user must have unique address Every registration request will be reviewed/authenticated, and must connect through valid business address If a CMAP provider practice or group has more than one provider, additional physicians can be registered under primary name Provider/practice can submit requests for each provider affiliated with facility TIN in CAREPortal 25

27 CAREPortal Registration Process After CAREPortal registration is entered by user and validated by imaging team: Requester will receive an with username and temporary password User must log in to the CAREPortal and change temporary password to permanent one Registration requests processed within 1-3 business days 26

28 Submitting Prior Authorization Online Step 1: Log onto the portal Step 2: Home page is displayed. Click on: 27

29 Submitting Prior Authorization Online Step 3: Search for Member User, then search for member. Member ID# and at least one other item is required for lookup. 28

30 Submitting Prior Authorization Online Step 4: Verify Member Eligibility and click on Next to continue 29

31 Submitting Prior Authorization Online Step 5: Select and Confirm the Ordering/Referring CMAP Provider 30

32 Submitting Prior Authorization Online Step 6: Select and confirm the Rendering Facility 31

33 Submitting Prior Authorization Online Step 7: Fill In the Required Fields Including Requested Procedure Code(s) and Primary Diagnosis Code(s) 32

34 Submitting Prior Authorization Online Step 8: Select the patient s signs and symptoms from the Clinical Criteria Tree that correspond with your requested procedure(s) 33

35 Submitting Prior Authorization Online Step 9: Review confirmation message with request reference KR# and status of request (Pending or Approved) 34

36 Claims Submission Process Professional claims: Claims must be submitted with CPT code and number of units authorized Claims submitted for bilateral studies are required to be submitted with CPT Code and Modifier RT on one detail line and CPT code and Modifier LT on separate detail line - each for one unit Claims submitted for the professional component of a radiology study must be submitted with modifier 26 Institutional claim form Revenue codes 35X, 404, 61X and 34X submit are required to be submitted with CPT code and number of units 35

37 Web Resources The Radiology Benefit Management Program offers useful tools, information and news for physicians and payer 24/7 online through: On the site you may: View Clinical Criteria View Brief Reference Guide to Imaging Download Prior Authorization Request Fax Form Access CAREPortal Request prior authorizations Perform a status check on authorization Tech Support Available for Questions or Concerns: Call

38 Questions & Answers

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