Medicare Advantage Radiology Prior Authorization Program Overview for Physicians, Facilities, & Other Healthcare Professionals

Transcription

1 Medicare Advantage Radiology Prior Authorization Program Overview for Physicians, Facilities, & Other Healthcare Professionals onals

2 Accessing Teleconference s Presentation 2 Select Tools & Resources Select Welcome Kit for New Physicians and Providers Select Florida Medicare Go to Clinical Programs & Product Information box Double click on Radiology Prior Authorization Presentation

3 Imaging Trends Drivers of Imaging Spending More people are accessing care now than previously More non-radiologists have access to imaging technology New technology in imaging is growing significantly, and appropriately so Utilization by providers is widespread (everyone is doing a little) and not concentrated in a few specialties 3

4 Balancing Challenges & Opportunities Imaging Challenges Rapid & sustained growth Widespread use & availability of expensive technology Significant variations in: Quality Safety Appropriate Utilization Increasing patient safety risks from: high cumulative levels of radiation overexposure to ionizing radiation Imaging Opportunities Improve quality and affordability Promote administrative consistency: Align requirements across Commercial & Government programs Enhance application of current scientific clinical evidence with professional society guidance Reduce health resource waste Reduce unnecessary radiation exposure 4

5 One Solution: Radiology Benefit Management Programs Prior Authorization for Advanced Imaging Studies In congruence with our Commercial Radiology Notification Program, and in alignment with our evidence-based medicine philosophy, this Prior Authorization Program is designed to: Support physicians in their decision-making process. Identify and avoid duplication of diagnostic services. Discuss the appropriateness of imaging services prior to being rendered. Enhance consistency between the use of diagnostic imaging studies and current scientific clinical evidence and professional society guidance. Maximize member benefits by providing information regarding the most current clinical and technical practices. Reduce unnecessary radiation exposure to our members. 5

6 Medicare Advantage Radiology Prior Authorization Program The Medicare Advantage Radiology Prior Authorization Program is a prior authorization process required for SecureHorizons and Evercare participating physicians, health care professionals, facilities and ancillary providers for certain advanced outpatient imaging procedures, prior to performance, with administrative claim denial for non-compliance and clinical claim denial for lack of medical necessity. A Prior Authorization number must be obtained, in accordance with the Radiology Prior Authorization process, prior to performing outpatient imaging procedures. Failure to complete the Radiology Prior Authorization process will result in an administrative denial (global and technical claim components). If the Radiology Prior Authorization process is completed, but the requested procedure is not authorized due to failure to meet clinical criteria, and the physician renders the unauthorized service, the claim will deny for lack of medical necessity (global, technical, and professional claims components.) 6

7 In-Scope Modalities & Places of Service (POS) Modalities In alignment with our Commercial Radiology Notification Program, the following modalities* are subject to this new Prior Authorization process for Medicare Advantage plans: CT Scans MRIs MRAs PET Scans Nuclear Medicine & Nuclear Cardiology Studies *A complete list of CPT Codes requiring Prior Authorization is available at: UnitedHealthcareOnline.com > Clinician Resources > Radiology > Radiology Notification & Authorization > Authorization Resources: Reference Materials Place of Service Prior Authorization is required in the following outpatient settings: Outpatient Hospital Locations Freestanding Imaging Centers (Stationary and Mobile) Physicians Offices Prior Authorization is not required for imaging services delivered in: Inpatient Hospital Locations Emergency Rooms Observation Units of Hospitals Urgent Care Centers 7

8 In-Scope & Out-of-Scope Plans INCLUDED PLANS (All transacted on the UnitedHealthcareOnline.com secure web site and subject to the UnitedHealthcare Provider Administrative Guide) AARP MedicareComplete, SecureHorizons MedicareComplete and UnitedHealthcare MedicareComplete Plans for both individual and employer group members, and group plans sold under UnitedHealthcare Group Medicare Advantage (PPO). Evercare Health Plans for People with Limited Incomes (Evercare Plans DH, DH-POS, DH-U, DP and RDP) Evercare Health Plans for People with Specific Long Term Illnesses (Evercare Plans MH, MH-POS, MP, and RMP) EXCLUDED PLANS Plans that use UnitedHealthcareOnline.com but have fully Capitated networks: Florida: AARP Medicare Complete Plan 1, HMO Gatekeeper Product Group Existing process of obtaining authorization from Managed Service Organizations will continue. Evercare Health Plans for People in Nursing Homes (Evercare Plans IH, IH-POS and IP) AmeriChoice Medicare Advantage Plans (including plans labeled Personal Care Plus) Sierra or Senior Dimensions Medicare Advantage plans Erickson Advantage Plans SecureHorizons and UnitedHealthcare Medicare Direct Private Fee for Service (PFFS) plans Medicaid-only plans Please note that our Medicare Advantage plans supported by other systems, including PacifiCare (pacificare.com), Oxford (oxfordhealth.com), and AmeriChoice (americhoice.com) have existing radiology prior authorization requirements. Those existing requirements are not changing. This program will not apply to these plans. 8

9 Prior Authorization Process: Ordering Physician s Responsibilities The ordering physician s office requesting the imaging service is responsible for obtaining a Prior Authorization number prior to scheduling advanced outpatient imaging procedures. Prior Authorization can be obtained via the same channels as the Radiology Notification Program: Online: UnitedHealthcareOnline.com Phone: Fax: The need for Prior Authorization is based on the location of the ordering physician. Only ordering physicians located in currently active states are required to obtain Prior Authorization. The ordering physician/provider may also verify if a Prior Authorization request has been approved by either: Checking the status online at UnitedHealthcareOnline.com Calling , selecting Prompt #2 and then selecting the appropriate Option for Medicare Advantage members 9

10 Prior Authorization Process: Rendering Provider s Responsibilities Prior to performing any in-scope advanced imaging study, the rendering provider should confirm that a Prior Authorization is on file by contacting UnitedHealthcare: Online: UnitedHealthcareOnline.com Phone: If the rendering provider determines there is no Prior Authorization on file, he/she should contact the ordering provider and request the ordering physician/provider obtain a Prior Authorization number before scheduling or performing the service. Written Prior Authorization is provided upon request to rendering providers by calling and selecting the Option for Medicare Advantage members. 10

11 Prior Authorization Process: Ordering Physician is Non-Participating If the ordering physician/provider is non-participating, the following options are available: Non-participating physicians can still submit a Prior Authorization either through UnitedHealthcareOnline.com, if they are registered, or by calling and selecting the Option for Medicare Advantage members. The rendering provider may request a Prior Authorization on behalf of the non-participating ordering physician by calling , selecting the Option for Medicare Advantage members and selecting Option 5 to speak with a Customer Care Professional. The Customer Care Professional will assist with obtaining an Prior Authorization number on behalf of the non-participating ordering physician *To speak to a Customer Care Professional regarding eligibility, benefits and claims: Call Select claims for claims payment and appeals Select benefits and eligibility to 1) Check if patient requires notification, 2) Check physician eligibility or 3) Miscellaneous provider/benefit questions 11

12 Evidence-Based Clinical Guidelines If the imaging procedure is consistent with the Medicare Advantage Radiology Prior Authorization Program s clinical guidelines, a Prior Authorization number will be communicated immediately. A copy of our evidence-based clinical guidelines may be obtained by visiting UnitedHealthcareOnline.com: Select Clinician Resources Select Radiology Select Radiology Notification & Authorization Select Authorization Resources: Reference Materials Select Evidence-Based Clinical Guidelines Imaging under the Reference Materials heading Note: The clinical guidelines used for this program were developed by a committee of practicing academic and community based radiologists and specialty consultants. They are based on Local and National Coverage Determinations, supplemented by guidelines and standards published by nationally and internationally recognized medical societies supplemented by material from peer-reviewed literature. 12

13 Modifying a Prior Authorization Request In an instance where a CPT code for the authorized procedure differs from the CPT code for the rendered procedure, the rendering physician must modify the request*. To modify a request, the rendering physician will need to provide the Prior Authorization number and any pertinent supporting clinical documentation: Call Select Option 5 Select Option 3 ~or~ Go to UnitedHealthcareOnline.com Select Radiology Notification & Authorization - Submission & Status Log in with User ID and Password Select Notification & Authorization Status Look Up Enter the case number or Prior Authorization number and select Edit *The rendering physician has up to 2 business days from the date of service to request a modification. 13

14 CPT Code Crosswalk Table Under the CPT Code Crosswalk Table, for certain specified CPT Code combinations, physicians and other health care professionals will not be required to contact the Radiology Prior Authorization Program to modify the existing authorization record. To access the CPT Code Crosswalk Table, go to UnitedHealthcareOnline.com Select Clinician Resources Select Radiology Select Radiology Notification & Authorization Select Authorization Resources: Reference Materials Select Radiology CPT Code Crosswalk Table under the Reference Materials heading For code combinations not listed on the CPT Code Crosswalk Table, the Radiology Prior Authorization protocol will still apply and a modification to the authorized procedure would need to occur. 14

15 Expired Prior Authorization Requests Expired Prior Authorization requests may be reactivated for up to 45 calendar days from the initial request date. The Prior Authorization number is valid for 45 calendar days. When a Prior Authorization number is entered for a procedure, SecureHorizons and Evercare will use the day Prior Authorization was issued as the starting point for the 45 calendar day period in which the examination must be completed If a procedure is not completed within 45 calendar days, a new Prior Authorization number must be obtained Reactivation can be completed at the physician level by: Call Select Option 4 15

16 Urgent Requests: Normal Business Hours Ordering physicians or their designee may request a Prior Authorization number on an urgent basis if the physician/provider determines it to be medically required. Urgent requests should be requested via phone by: Call Select Option for Medicare Advantage members and then selecting Option 1 The physician/provider must state the case is clinically urgent and explain the clinical urgency when speaking with a Customer Care Professional. A Prior Authorization number will be issued for urgent requests within three (3) hours after UnitedHealthcare receives all required information. 16

17 Urgent Requests: Outside Normal Business Hours Ordering physicians or their designee may request a Prior Authorization number on an urgent basis if the physician/provider determines it to be medically required. If an advanced outpatient imaging procedure is required on an urgent basis and Prior Authorization cannot be obtained because it is outside of normal business hours, the service may be performed and authorization requested retrospectively. Services performed outside of normal business hours include services rendered on an urgent basis outside the hours of 7:00am to 7:00pm (all time zones) or on weekends, and or on standard U.S. national holidays. Retrospective authorization requests must be made within two (2) business days of the provision of the service. Note: Prior Authorization is not required for imaging services provided in an Inpatient, ER, Observation, or Urgent Care Clinic setting. 17

18 Case Number vs. Prior Authorization Number A Case Number is assigned to every request. Case numbers are used for reference purposes only (i.e. physicianto-physician discussion) Case numbers are not valid for claim payment The format is a 10-digit numeric value: Example: A Prior Authorization Number will be given immediately for every case that is consistent with evidence-based clinical guidelines. The format is the letter A followed by a 9-digit numeric value and the CPT code: Example: A

19 Communicating Prior Authorization Numbers Prior Authorization numbers for cases meeting evidence-based clinical guidelines are communicated to the ordering providers or their designees: For cases initiated by online: The Prior Authorization number will be provided immediately upon case completion on the web. The Prior Authorization number will also be faxed within 15 minutes to the ordering physician/designee. For cases initiated by phone: The Prior Authorization number will be given by the Customer Care Professional while on the call. The Prior Authorization number will also be faxed within 15 minutes to the ordering physician/designee. For cases initiated by fax: The Prior Authorization number will be faxed to the ordering physician/designee. For cases requiring a physician-to-physician discussion: The Prior Authorization number will be given by the physician while on the call. The Prior Authorization number will also be faxed within 15 minutes to the ordering physician/designee. 19

20 Initiating a Prior Authorization - Online To initiate a request online, go to UnitedHealthcareOnline.com Select Notifications > Radiology Notification & Authorization - Submission & Status. * Consider disabling popup blockers that may prevent access to the web notification feature. Log in using your User ID and Password. Enter the following information: Physician's tax ID and fax number Patient's ID, group number and date of birth (DOB) Requested study and/or CPT code Diagnosis code Clinical information pertaining to the requested study (i.e. medication, findings of recent physical examination; results of lab blood tests; recent CT, MR, or PET results; biopsy results) 20

21 Initiating a Prior Authorization - Phone To initiate a request by phone, call Select Option 1 (request Prior Authorization). The phone process will require the following minimum information: Physician's tax ID, fax number and first initial of physician s last name Patient's ID, group number and Date of Birth (DOB) Requested study and/or CPT code Diagnosis code Clinical information pertaining to the requested study (i.e. medication, findings of recent physical examination; results of lab blood tests; recent CT, MR, or PET results; biopsy results) 21

22 Initiating a Prior Authorization - Fax To initiate a request by fax, obtain a Prior Authorization request form, available at UnitedHealthcareOnline.com Select Clinician Resources > Radiology > Radiology Notification & Authorization > Authorization Resources: Modality-specific Fax Forms - Now Interactive! * The following downloadable, modality-specific forms are available: CT/CTA PET MR/MRA Generic Print and fill out the appropriate modality-specific form. The following information is required: Physician's tax ID and name, phone and fax Patient's ID, name, group number and Date of Birth (DOB) Requested test and/or CPT code Diagnosis code Clinical information pertaining to the requested study (i.e. medication, findings of recent physical examination; results of lab blood tests; recent CT, MR, or PET results; biopsy results) Fax the completed form to

23 Verifying Status of Existing Prior Authorization Request To verify the status of an existing prior authorization request online: Go to UnitedHealthcareOnline.com Login with User ID and Password Select Notifications Select Radiology Notification & Authorization - Submission & Status Select the owner physician ID, Tax ID, and name from pull down listing Select Notification Status Lookup A search may be done by using any two of the following criteria: Provider's Tax ID Case Number Notification Number Patient ID To verify the status of an existing prior authorization request by phone: Call , select Option 2 Select Option 1 to verify status using a case number Select Option 2 to verify status using patient's ID 23

24 Radiology Prior Authorization/Notification Program Comparison Program Scope UnitedHealthcare Medicare Advantage Radiology Prior Authorization Program UnitedHealthcare Radiology Notification Program Program Type Prior Authorization Notification UnitedHealthcare Line of Business Medicare (AARP/ Evercare/ Secure Horizons) Commercial In-Scope Modalities CT, MRI/ MRA, PET & Nuclear Medicine/Cardiology CT, MRI/ MRA, PET & Nuclear Medicine/Cardiology Request Methods Web: UnitedHealthcareOnline Phone: Fax: Web: UnitedHealthcareOnline Phone: Fax: In-Scope Places of Service Outpatient Hospital, Freestanding Imaging Centers, Physician Offices Outpatient Hospital, Freestanding Imaging Centers, Physician Offices Out-of-Scope Places of Service Inpatient Hospital, Emergency Room, Observation Units, Urgent Care Centers Inpatient Hospital, Emergency Room, Observation Units, Urgent Care Centers 24

25 Radiology Prior Authorization/Notification Operational Comparison Operational Impact Claim Denial Type Which claims are subject to admin denial for no auth? Which claims are subject to clinical denial for lack of medical necessity? What is the impact to nonparticipating ordering physicians? What is the impact to Hospital Based Physicians (HBP)? Under what scenarios may the provider balance bill the member? UnitedHealthcare Medicare Advantage Radiology Prior Authorization Program Admin denial for no auth; Clinical denial for lack of med necessity Global Technical (TC) Global Technical (TC) Professional (26) Non-par ordering physicians can request an authorization, or par rendering providers may request an authorization on behalf of the non-par ordering physician Prof claims are subject to clinical denial for lack of medical necessity Member may be balanced billed if the procedure is not authorized, but is performed, regardless, with the member s permission UnitedHealthcare Radiology Notification Program Admin denial for no notification Global Technical (TC) N/A Non-par ordering physicians can request a notification, or par rendering providers may request a notification on behalf of the non-par ordering physician Prof claims are not subject to admin denial for no notification Members may not be balanced billed 25

26 Claims Key Points To Remember Global and Technical service claims are subject to administrative denial of payment for failure to request Prior Authorization. The member may not be balanced billed. Radiology claims administratively denied for no Prior Authorization are identified using the remark code 0026 Notification Required. Professional only (-26 modifier) service claims submitted for imaging interpretation are subject to the Radiology Prior Authorization requirements. If the Radiology Prior Authorization process is completed, but the requested procedure is not authorized due to failure to meet clinical criteria, and the physician renders the unauthorized service, the claim will deny for lack of medical necessity (global, technical, and professional claims components. Primary/Secondary: No Prior Authorization is required when SecureHorizons and/or Evercare Medicare Advantage is secondary to any other payer, including UnitedHealthcare Commercial. 26

27 Claims Key Points To Remember (cont d) Receipt of a prior authorization number does not guarantee or authorize payment. Payment of the covered services is contingent upon the Member being eligible for services on the date of service, the provider being eligible for payment, the service being a covered benefit given Local and National Coverage Determinations and any claim processing requirements. There are no changes to the current UnitedHealthcare process for claim questions or appeals. There is no need to include the Prior Authorization number on the claim form; however, the provider may do so at their discretion. Members may be balanced billed if: Service was deemed as medically unnecessary following a prior authorization request. Provider obtained written consent from the member to proceed and perform the service (written consent must be specific to the service and must explain the costs). For questions about claims call

28 Additional resource information is available online. Go to UnitedHealthcareOnline.com > Clinician Resources > Radiology > Radiology Notification & Authorization Frequently Asked Questions (FAQs) Quick Reference Guide (QRG) Plan Inclusion/Exclusion Grid Evidence-Based Clinical Guidelines Imaging Radiology CPT Code List requiring prior authorization Radiology CPT Code Crosswalk Table Modality-specific fax forms and more! Available Tools & Resources 28

29 Questions & Answers Thank You For Your Participation! 29