New Imaging Management Solution Frequently Asked Questions

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1 New Imaging Management Solution Frequently Asked Questions Beginning July 1, 2014, HealthKeepers, Inc. will require prospective clinical case review (prior authorization) for outpatient, nonemergent imaging for our members enrolled in Anthem HealthKeepers Medicare-Medicaid Plan (MMP) to be obtained through AIM Specialty Health (AIM). Anthem HealthKeepers MMP is a Commonwealth Coordinated Care plan. The following services are included in the program: Computed tomography (CT/CTA) scans, including cardiac Magnetic resonance (MRI/MRA), including cardiac Positron emission tomography (PET) scans, including cardiac Nuclear cardiology This document provides information on the new requirement to help you answer questions from providers. 1. What is AIM Specialty Health? AIM is a leading specialty benefits management company with more than 20 years of experience and a growing presence in radiology, cardiology, oncology, sleep medicine and specialty drug management. AIM s mission is to make health care services more clinically appropriate and affordable, as well as safer. As such, AIM promotes the most appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services. 2. Why is HealthKeepers, Inc. focusing on diagnostic imaging? Diagnostic imaging is one of the most important clinical tools available to providers and patients. However, a growing number of studies have shown that a high proportion of imaging tests performed are not clinically appropriate. At an average cost per test of $500 to $900, the costs of inappropriate imaging are staggering. Cardiovascular imaging, in particular, represents a full third of the several billion medical imaging examinations performed worldwide on an annual basis. Yet several studies have indicated that up to 15% of cardiac imaging exams are inappropriate based on Appropriate Use Criteria (AUC) issued by the American College of Cardiology (ACC). 3. When will this program begin? Beginning July 1, 2014, AIM s website, ProviderPortal SM, and call center will be available for submission of order requests for imaging services occurring on or after July 1, How does a provider office staff member obtain an order number from AIM? There are two ways to obtain an order number for diagnostic imaging services: Providers may contact AIM online via AIM s ProviderPortal. They will need to log in as a registered user or register to access the portal. Call toll-free: Hours of operation are Monday through Friday, 8:00 a.m. 8:00 p.m. Eastern time. HealthKeepers, Inc. is a health plan that contracts with both Medicare and the Virginia Department of Medical Assistance Services to provide benefits of both programs to enrollees. HealthKeepers, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AVAPEC /01/2014

2 5. How does the program work? Anthem HealthKeepers MMP Page 2 of 6 Ordering provider offices submit requests through ProviderPortal, AIM s interactive website, or through the AIM call center. Web users or callers will be guided through an interview where member and ordering provider s information, diagnosis, symptoms, exam type and treatment/clinical history will be requested. If the information provided meets AIM s clinical criteria and is consistent with HealthKeepers, Inc. s medical policy, the web user/caller will be guided to select an imaging provider where the imaging study will be performed. An order number will also be issued. If all criteria are not met or additional information or review is needed: The case is forwarded to a registered nurse (RN) reviewer. The RN reviewer uses additional clinical experience and knowledge to evaluate the request against clinical guidelines. The RN reviewer has the authority to issue order numbers in the event that he or she determines that the request is consistent with AIM s clinical criteria and HealthKeepers, Inc. medical policy. If an order number still cannot be issued, the RN reviewer will contact the ordering provider to schedule a peer-to-peer discussion with an AIM physician (MD) reviewer. The physician reviewer can approve the case based on a review of information collected or through their discussion with the ordering provider. The AIM physician reviewer will refer the case back to HealthKeepers, Inc. when one or more of the following occurs: The AIM physician reviewer cannot approve the case based on the information previously collected. The AIM physician reviewer is unable to reach the ordering provider to discuss the case. The AIM physician reviewer is unable to approve the case based on the information supplied by the ordering provider during the peer-to-peer discussion. 6. What does the AIM order number look like? AIM s order numbers are eight digits in length. 7. How long is an order number valid? An order number issued by AIM is valid for 30 days. 8. Can AIM handle multiple requests per call? Yes, imaging requests for multiple members can be made on the same call. 9. Does AIM need to know when the procedure is scheduled? No, although the order number should be issued prior to scheduling the study. ProviderPortal prevents a retrospective case from being created. 10. Can members contact AIM? Members should contact HealthKeepers, Inc. directly if they have any questions.

3 Anthem HealthKeepers MMP Page 3 of What information will AIM require in order to evaluate an imaging request? Please refer to the checklist below to ensure you have all the necessary information available prior to submitting a request to AIM: Member s name, date of birth and HealthKeepers, Inc. health plan ID number Ordering provider information Imaging provider information Imaging exam(s) being requested (body part, right, left or bilateral) Patient diagnosis (suspected or confirmed) Clinical symptoms/indications (intensity/duration) For most situations, the above will suffice. For complex cases, more information may be necessary, including the results of past treatment history (previous tests, duration of previous therapy, relevant clinical medical history). 12. How can I determine whether an order number has been obtained for a member? To determine whether an order number has been obtained for a member enrolled in HealthKeepers, Inc, call AIM at Or go to the AIM website. Providers will need to log in as a registered user or register to access the portal. 13. What happens if a member is approved for a specific procedure (e.g., a CT scan of the abdomen) and during the course of this procedure, the radiologist or rendering provider feels that an additional procedure (e.g., a CT scan of the pelvis) is required that also requires precertification? The radiologist or rendering provider should proceed with the additional procedure. If this occurs, he or she should inform the member s ordering provider that an additional test was performed on the same day. AIM must be contacted for an order number for the additional procedure no later than two business days after the service was rendered. The pertinent clinical information supporting the additional procedure must be available at the time AIM is contacted. 14. If a service is already authorized by AIM and needs to be rescheduled beyond the original 30-day authorization period, do I need a new order number? If the date of the service is extended beyond the original 30-day authorization period, a new authorization must be requested through AIM. 15. If the authorization is done via the telephone or via the ProviderPortal, is a letter sent to the provider regarding approval or denial of the authorization? Yes, approval or denial letters will be sent to ordering providers who request precertification of high-tech radiology imaging services. A case received on Monday must be closed by 5 p.m. Eastern time on Wednesday For standard authorizations, AIM must issue a decision within two business days of obtaining all necessary information; however, they have up to 14 calendar days to make the decision if they have not received all necessary information. For expedited authorizations, AIM must issue a decision within three business days of obtaining all

4 Anthem HealthKeepers MMP Page 4 of 6 necessary information; however, AIM also has up to three working days to issue a decision if they do not receive all the necessary information. 16. What Pre-Exam Questions (PEQs) will be asked? HealthKeepers, Inc. requests that the ordering provider complete a set of voluntary PEQs for cardiac exams, including Cardiac CT/CTA and Cardiac PET. For example, the following questions/requests for information will be asked for Myocardial Perfusion Imaging (MPI) and Spine Echo (SE): Differential diagnosis Does the patient have established coronary artery disease (CAD)? If yes, please indicate which exams were performed and when. o Myocardial infarction o Angioplasty, stenting or bypass o Catheterization showing > 70% stenosis Does the patient have chest pain? If yes, please provide additional information (nature/description/location). Does the patient have any additional symptoms? If yes, please describe the additional symptoms. Patient Risk Assessment: o Current weight o Current blood pressure o Current smoker o Current total cholesterol o Coexisting conditions (diabetes, abdominal aortic aneurysm, symptomatic peripheral vascular disease, history of CVA/TIA/CEA, renal insufficiency/failure) o Family History of CAD (Father/Brother/Son < 50 years old, mother/sister/daughter < 60 years old) When did the patient last receive an EKG? Please provide the results of the most recent EKG test. Is the patient able to walk on a treadmill? Has the patient received any cardiac exam/test in the last two years? If yes, please provide the date and results for the exam(s). o Exercise stress test o Coronary CT angiography o Cardiac catheterization Preoperative evaluation (if performing surgery, please indicate type and date) Does the patient have a history of heart transplant?

5 17. Why is HealthKeepers, Inc. requesting PEQs? Anthem HealthKeepers MMP Page 5 of 6 PEQs are included in the review process for cardiac imaging exams to risk-stratify patients by identifying the common risk factors for cardiac disease. The PEQs address blood pressure, lipid status, tobacco use and diabetes. 18. If I do not complete the PEQs, will there be an impact on my cardiac imaging services order request results? While the completion of the PEQs for Cardiac CT/CTA, Cardiac PET, MPI and SE is currently voluntary, it is important to note that, because these exams are used to assess the risk of CAD, they facilitate the order review process. Completing the PEQs for these exams will reduce the time it takes for you to receive an order number. Because there is no correlation between CAD and all other cardiac exams (TTE, TEE, Blood Pool Imaging/MUGA and Cardiac MRI), PEQs for adult patients are not included. In addition, because the PEQs do not currently take age into consideration, they will not be requested for pediatric patients (under the age of 19). 19. How do I complete the PEQs? Complete PEQs when submitting your request via the web or by phone for an order number for cardiac imaging services. 20. Who develops the clinical criteria for the program? Clinical appropriateness guidelines developed by AIM are updated at least once a year and are reviewed by: An independent physician review board, including cardiologists, orthopedic surgeons, radiologists, neurologists and neurosurgeons Client medical directors Local imaging advisory council (representing local physician communities) Physician review panels In addition, AIM s guidelines are submitted as part of AIM s accreditation process to the National Committee for Quality Assurance (NCQA) and the American Accreditation HealthCare Commission (URAC). 21. What methods and resources are used to develop the guidelines? Development of AIM s clinical appropriateness guidelines involves integration of medical information from multiple sources to support the reproducible use of high quality and state-of-the-art diagnostic imaging services. The process for criteria development is based on technology assessment, peer-reviewed medical literature, including clinical outcomes research, and consensus opinion in medical practice. The primary resources used for AIM s diagnostic imaging clinical appropriateness guidelines development include: American College of Radiology Appropriateness Criteria American College of Cardiology Appropriateness Criteria American Heart Association

6 Anthem HealthKeepers MMP Page 6 of 6 American Institute of Ultrasound in Medicine American Cancer Society American Academy of Neurology American Academy of Pediatrics Society of Interventional Radiology Society of Nuclear Medicine Agency for Healthcare Research and Quality Centers for Medicare and Medicaid Services National Guideline Clearinghouse

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