RADIATION THERAPY MANAGEMENT PROGRAM CARECORE NATIONAL FREQUENTLY ASKED QUESTIONS FOR MVP PROVIDERS

Transcription

1 RADIATION THERAPY MANAGEMENT PROGRAM CARECORE NATIONAL FREQUENTLY ASKED QUESTIONS FOR MVP PROVIDERS Evidence-Based Healthcare Solutions CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC

2 TABLE OF CONTENTS Can you provide me with an overview of this program?...1 What if I have a patient who is beginning treatment prior to October 29, 2012?...1 What is the best way to obtain a Medical Necessity Determination and pre certification?...2 What is the extent of CareCore s ability to issue a pre certification online?...2 Can Physician Worksheets be submitted via fax?...2 Does the program include inpatient services?...2 Is there a way to delete a physician after he or she has been added to a web account?...3 How long does it take to receive a determination after a case is submitted?...3 What is the timeline for a peer to peer consultation?...3 Is there a way to verify whether a Medical Necessity Determination number has been assigned to a MND request?...3 How long do authorizations last?...3 Can a Medical Necessity Determination number expire?...3 Which Places of Service require a Medical Necessity Determination?...3 Is a Medical Necessity Determination required if the treatment plan is administered at a hospital outpatient facility?...3 Will urgent requests be accepted?...3 Can we file an appeal for cases that have been denied or partially denied?...3 Are the clinical criteria available for review?...4 Our system bills on a monthly basis. Is this a problem?...4 Does the authorization number need to be on the claim?...4 CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC

3 What length of time is necessary for a case to go through the medical review process?...4 What if a physician does not agree with CareCore s determination?...4 What if a claim has been denied?...5 What is a partial approval notice?...5 If a member changes referring providers, will a new Medical Necessity determination be required?...5 Is a new Medical Necessity Determination required if the patient requires additional treatment (such as a recurrence of disease or change in patient clinical condition)?...5 Can a Medical Necessity Determination be obtained for multiple sites of therapy for the same patient at the same time?...5 Who is responsible for obtaining a Medical Necessity Determination and pre certification?...5 If the patient begins radiation therapy treatment with one Radiation Therapy facility and decides to change Radiation Therapy facilities (different TIN) during a course of treatment, is a new Medical Necessity Determination required?...5 When providing Radiation Therapy services, what cancer types will require a Medical Necessity Determination?...6 What information is required from the physician for a Medical Necessity Determination?...7 If a radiation consult and simulation are done on the same day, is it required to receive a precertification before simulation?...8 What will a Radiation Therapy Medical Necessity Determination authorize?...8 What are the main components of the authorization letter?...8 Are chemotherapy drugs included in this program?...8 CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC

4 General Policies and Procedures Q: Can you provide me with an overview of this program? A: MVP developed the Radiation Therapy Authorization Program in an effort to help ensure that the radiation therapy services provided to our members are consistent with nationally recognized clinical guidelines. The program promotes quality and patient safety for our members who require radiation therapy services. Effective with dates of service beginning October 29, 2012, pre certifications will be required for select outpatient radiation therapy services performed in either a professional or facility setting. Specialists, such as radiation oncologists who formulate the treatment plan and provide and/or coordinate the radiation therapy treatment, will be responsible for requesting medical necessity determinations MVP members whose coverage requires authorization. MVP has partnered with CareCore National, LLC to support the Radiation Therapy Authorization Program by completing medical necessity reviews and authorizations where applicable for select outpatient radiation therapy services. CareCore National (CareCore) is a specialty benefit management company that has provided specialized management of oncology drugs and therapeutic agents since They have developed diseasespecific, evidence based criteria to manage the appropriate utilization of radiation therapy services. By ensuring that patients receive the most appropriate treatment the first time, CareCore helps to eliminate the cost and time wasted with inappropriate treatments while assuring the highest levels of patient safety. Q: What if I have a patient who is beginning treatment prior to October 29, 2012? A: For MVP patients beginning radiation therapy prior October 29, 2012 who will continue therapy beyond that date, the patient s treatment plan must be registered with CareCore to ensure accurate claims payment for claims submitted after October 29, This will not impact the patient s existing treatment plan. Registration of these patients treatment plans can be done via the MVP Radiation Therapy Provider web portal. Providers can register for a User ID and Password from CareCare by selecting the Register button at Providers or Provider Representatives will need to provide contact and user information to include the following: Contact Name Address Address Phone In addition information on each physician that will be associated with each account must also be provided: Physician Name CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC PAGE 1 OF 7

5 Tax ID NPI Provider Numbers as assigned by each Health Plan Providers not yet registered on the MVP Provider Web Portal can call CareCore direct at Toll free service lines are available Monday through Friday from 7 a.m. to 7 p.m. (local). When registering a treatment plan, the following information is needed: Patient s Name and Member ID Cancer Diagnosis being treated Treatment start date NPI or Provider ID of ordering physician or other health care professional Rendering Facility Name and ID Note: Treatment plans should also be registered for those patients who started treatment while covered through another health insurer but then obtained MVP coverage. This applies to patients who began treatment prior to October 29, 2012 and will continue treatment after October 29, Q: What is the best way to obtain a Medical Necessity Determination and pre certification? A: The fastest way for physicians to achieve a Medical Necessity Determination is by visiting the CareCore National Provider Portal and submitting a request for Radiation Therapy services through the web. Medical Necessity Determination decisions can be provided immediately online. If you do not have access to the internet, then you can request a Medical Necessity Determination by calling CareCore National at Q: What is the extent of CareCore s ability to issue a pre certification online? A: The CareCore National Provider Portal website will allow physicians to order Radiation Therapy services online and obtain a pre certification online in real time. Physicians unfamiliar with the website s capabilities can access a web use training module online from The provider portal on the CareCore website is the quickest and easiest means of securing precertification. Q: Can Physician Worksheets be submitted via fax? A: No. All requests for Medical Necessity Determinations and pre certifications must be submitted online or by phone. Q: Does the program include inpatient services? A: No, this is an outpatient only program. CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC PAGE 2 OF 7

6 Q: Is there a way to delete a physician after he or she has been added to the web account? A: A user can always delete a physician. There is a REMOVE button on the Manage Account page where the physicians are listed. Q: How long does it take to receive an answer after a case is submitted? A: If the request goes through the clinical pathway without hitting any of the rules that force the case to go to a clinical reviewer, the approval is instantaneous. This process can take up to two days, but is most often much shorter. The pre certification timeline is further governed by applicable state regulations. Q: What is the timeline for a peer to peer consultation? A: The average length of time for a peer to peer to be scheduled is between one and two hours. CareCore may have more or less time to complete the peer to peer consultation according to applicable state regulations. Q: Is there a way to verify whether a Medical Necessity Determination number has been assigned to a MND request? A: Yes, please check the CareCore National Provider Portal website at and click on Authorization Lookup. Q: How long do the authorizations last? A: The authorization expiration date varies by the case. CareCore communicates the expiration date once the approval is generated verbally and the information is also faxed to the office. If you think a longer length of time is necessary, then you may discuss this during a peer to peer consultation. Also, if a patient needs to stop treatment for some reason or needs a break from treatment, you may call CareCore and report the issue to receive an extension to the authorized treatment period. Q: Can a Medical Necessity Determination number expire? A: Yes, please check the CareCore National Provider Portal website at for expiration dates and click on Authorization Lookup. Q: Which Places of Service require a Medical Necessity Determination? A: All Participating PROFESSIONAL (office and outpatient) and OUTPATIENT INSTITUTIONAL claims require a Medical Necessity Determination. Q: Is a Medical Necessity Determination required if the treatment plan is administered at a hospital outpatient facility? A: Yes, as of October 29, 2012, Medical Necessity Determinations are required for in scope members. Q: Will urgent requests be accepted? A: Yes, urgent requests will be accepted and a determination expedited if clinically required. Q: Can we file an appeal for cases that have been denied or partially denied? CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC PAGE 3 OF 7

7 A: We recommend that you utilize the reconsideration process before filing an appeal. Reconsiderations are completed through peer to peer consultations, and allow our physicians to take your patient s particular circumstances into account. If the initial decision is upheld, then the next step is a first level appeal. See What if a physician does not agree with CareCore s determination and wants to file an appeal? on the following page. Q: Are the clinical criteria available for review? A: Yes, this document is available online through the CareCore National Radiation Therapy Program Tools and Criteria page at Q: Our system bills on a monthly basis. Is this a problem? A: As long as dates of service are within the authorized treatment period, you can bill monthly or weekly. Q: Does the authorization number need to be on the claim? A: No, there are no changes for submitting a claim. Q: What length of time is necessary for a case to go through the medical review process? A: Expedited cases will be resolved within 3 hours and a notification will occur within that timeframe. Standard approvals will be resolved and a notification will occur within two business days, but this typically requires no more than a single day. The turnaround times are dependent upon all necessary information being provided to CareCore. If there is insufficient information to make a determination when a case reaches a Medical Director for review, then a hold letter will be faxed to the provider s office indicating what information is still required. The surest way to avoid this scenario is to complete the appropriate physician worksheet before calling CareCore. Q: What if a physician does not agree with CareCore s determination and wants to file an appeal? A: The physician can contact the CCN Peer to Peer Consultation line. The physician will be able to discuss the case in detail with a CCN Medical Director. Toll Free: and select the Medical Director service menu option. The provider can appeal a clinical decision FOR COMMERCIAL MEMBERS in writing to: E mail: appealsfax@carecorenational.com Mail: CCN APPEALS DEPARTMENT 400 Buckwalter Place BLVD. Bluffton, SC CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC PAGE 4 OF 7

8 Q: What is a partial approval notice? A: This document will inform the provider of approved and non approved services for the requested treatment plan. It will also contain clinical appeal information. Q: If a member changes referring providers, will a new Medical Necessity Determination be required? A: No. However, if any changes occur to the case, CareCore should be notified. Q: Is a new Medical Necessity Determination required if the patient requires additional treatment (such as a recurrence of disease or change in patient clinical condition)? A: Yes. The Medical Necessity Determination is valid for the treatment plan that has been requested by the physician (an Episode of Care). If the physician is going to provide the member with another episode of care a new Medical Necessity Determination will be required. If during a course of treatment the physician intends to modify an approved treatment plan, then he or she should call CareCore to discuss the new treatment plan to allow the existing Medical Necessity Determination to be adjusted appropriately. The modifications to the Treatment Plan that are determined to be Medically Necessary will be communicated to the physician. Q: Can a Medical Necessity Determination be obtained for multiple sites of therapy for the same patient at the same time? A: Yes, after the therapy is deemed medically necessary and pre certified accordingly. Q: Who is responsible for obtaining a Medical Necessity Determination and pre certification? A: The Radiation Oncologist who has determined the radiation therapy treatment plan. Q: If the patient begins radiation therapy treatment with one Radiation Therapy facility and decides to change Radiation Therapy facilities (different TIN) during a course of treatment, is a new Medical Necessity Determination required? A: Yes. If the patient is seeing a new physician that is part of a different practice a new treatment plan will be devised, therefore, a new Medical Necessity Determination must be issued to the physician. Policies and Procedures Specific to Radiation Oncology Q: When providing Radiation Therapy services, what cancer types will require a Medical Necessity Determination? A: Bone Metastases Brain Metastases Breast Cancer Non Small Cell Lung Cancer Small Cell Lung Cancer Prostate Cancer Cervical Cancer CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC PAGE 5 OF 7

9 Rectal Cancer Head/Neck Cancer Endometrial Cancer Pancreatic Cancer Gastric Cancer Primary Central Nervous System Lymphoma Primary Central Nervous System Neoplasms Other Cancer: Other cancer types not specifically listed above Non Cancerous Indications needing radiation therapy Q: What information is required from the physician for a Medical Necessity Determination? A: Cancer type being treated with Radiation Therapy Patient Information Ordering Provider information Rendering Site information Patient History, to include: Recent test results Work up Current clinical condition Treatment Plan specifics which may include: Immobilization Techniques Treatment Plan Treatment Technique Fields/angles Fractions Boost **Provider worksheets specific to each Cancer Type are available on the CareCore National website at These worksheets list all clinical questions that are asked of the provider during the initial Precertification review either online or by phone. Please have the worksheets completed with the medical records present prior to the initiation of obtaining a pre certification. CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC PAGE 6 OF 7

10 Q: If a radiation consult and simulation are done on the same day, is it required to receive a precertification before simulation? A: If the radiation oncologist performs the initial consult and simulation on the same day, it is not required to receive a pre certification approval before simulation. The request for pre certification may be submitted after the consult and simulation are completed on the same day. If the simulation is scheduled on a day subsequent to the initial consult, please request the precertification after the initial consult. If there is a change in the treatment plan after the simulation is completed, you must contact CareCore to notify of the changes. Q: What will a Radiation Therapy Medical Necessity Determination authorize? A: One Medical Necessity Determination will authorize a complete treatment plan to include the consultation and planning timeframe. Q: What are the main components of the authorization letter? A: The authorization letter will include the authorization number, timeline for which the treatment is valid, type of technique, number of phases, number of gantry angles, number of fractions, select CPT codes, and claim instructions. Q: Are chemotherapy drugs included in this program? A: No. This program applies to radiation therapy treatment only. Q: If a treatment plan is partially approved or approved in its entirety and individual CPT codes will not be listed out, how will we know what is approved? For example, Image Guidance many codes fall under that type of test. A: You will be provided with the treatment modality, fractions, phases and gantry angles approved. If IGRT is requested, we ask the type of IGRT being requested. If it is approved, then the appropriate CPT code for the IGRT type should be billed based off of the ASTRO ACR guide to radiation oncology coding. Q: What information will be provided on a partially approved or approved plan of treatment? A: When a case is partially approved a letter to the physician will be sent with the approved services and the denied services from the request. CARECORE NATIONAL. 400 BUCKWALTER PLACE BOULEVARD, BLUFFTON, SC PAGE 7 OF 7