PRE-CERTIFICATION CHEAT SHEET

Transcription

1 PRE-CERTIFICATION CHEAT SHEET For any/all questions related to pre-cert call & ask for Pre-Cert This is strictly a GUIDE for pre-cert requirements. If an insurance or outpatient test is not listed below, CALL the health plan to verify pre-cert requirements. Include ALL Insurance ID#s & group #s on the order. When an insurance representative states pre-cert is " Not Required " ; document the date & time of the call, the phone # called and representatives name. This is VITAL info to have on the order for billing to appeal if denied; no order will be accepted as valid until this information is provided. IMPORTANT: When a request to change a test is made (by the radiologists protocol); a new auth or updated auth is needed immediately for denial prevention. Example(s): added body part or contrast level change If any insurance states "Auth is not required, but pre-determination is recommended"... the pre-determination must be obtained. These will get denied for no auth or for medical necessity issue at time of billing if not obtained. When using AIM (American Imaging Management) or NIA (National Imaging Associates) please be sure you are selecting the correct rendering facility: Wentworth Douglass Hospital with Tax ID: and NPI: INSURANCE COMPANY TESTS REQUIRING PRE- CERTIFICATION CONTACT INFORMATION NOTES AARP n/a n/a Auth not required as Medicare supplement policy *Most Aetna plans will give a call reference # for the call - Please put that # on the order, Caths, Echos, Infusions, *Authorization is also required as a secondary insurance Sleep Studies Aetna: including 2nd to Medicare Aetna Aetna Medicare (PFFS aka: Private Fee For Service plans are exempt and do not, Caths, Echos, Infusions, require authorization) Sleep Studies Aetna: American Republic Infusions Use # provided on insurance card *No authorization required when secondary to Medicare. APWU Call on all tests Cigna Care Allies: *WDH is not in network with Aetna Medicare plans, verify if the patient has out of network benefits before obtaining authorization. Call for auth on all tests if no auth is required obtain refrence number *No authorization required when secondary to Medicare. *All other tests, call the health plan directly to check pre-cert for notification Assurant Health MRI/MRA, CT/CTA, PET Health-Health Bankers Life n/a n/a Auth not required as Medicare supplement policy BC NATIONAL (Anthem) MRI/MRA, CT/CTA, PET, Angio/Cath, Nuclear, Echos, Nuclear Medicine, Infusions, Sleep Studies Call # on back of insurance card for precert requirements or call the National phone *Call on any/all Anthem BCBS plans not listed by State below *If Anthem States "Auth is not required, but predetermination is recommended"... the pre-determination must be obtained. These will be denied for no auth/medical necessity issues at time of billing if not obtained.

2 BC of Alabama BC of Alaska BC of Arkansas including WMW BC of California BC of Colorado BC of Connecticut BC of Florida BC of Georgia BC of Idaho BC of Kentucky BC of Louisiana BC of Maine (Prefix XVB only-exempt no authorization required) Care Core National: , Echos, Echos, Infusions, Echos, Infusions, Sleep Studies, Echos, Echos, Sleep Studies Infusions, NucMed Gated Blood Pool, Echos, Sleep Studies, Echos, Echos NIA (National Imaging Associates): Prefix WMW thru AIM: *Imaging//Sleep Studies thru AIM (American Imaging Management): *Call the health plan directly for Infusions & Nuc Med NIA (National Imaging Associates): *Imaging//Sleep Studies *Call the health plan, Echos, Sleep Studies, Sleep directly for Infusions & Sleep PSG PSG w/mslt, Infusions w/mslt (cpt 95805) *Obtain a reference # from representative if the rep states not required. *NIA Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) *If AIM states auth is not thru them, they will advise you to call the health plan directly please call the number listed on the back of card. *Sleep Studies require auth specifically thru Medical Management please use the number for providers on the back of the ID card. *Call the health plan directly for Infusions & Nuc Med *Sleep Studies require auth thru AIM effective:6/1/13 *NIA Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) *For any tests other than those listed call the health plan directly *Sleep Studies require auth thru AIM *Authorization is required as secondary to Medicare *If AIM states auth is not required thru them it will be required through the health plan. *Call the health plan directly for Infusions *Sleep Studies require auth thru AIM eff:6/1/13

3 BC of Mass HMO- (Authorization guidelines are based on the state the patients PCP resides. Example: if a patient has a Mass HMO policy with a NH PCP the Mass policy will follow NH guidelines for pre authorization see NH guidelines, Echos, Sleep Studies, Sleep below) PSG w/mslt, Infusions BC of Mass Liberty Mutual Plan Prefix LMH only BC of Mass PPO BC of Nebraska BC of Nevada BC of New Jersey Infusions/Injections *Pharmacy (for infusions): *Medical Management: *AIM (American Imaging Management): *Call Medical Management directly for Sleep PSG w/mslt (cpt 95805) Express Scripts (formally Medco/Accredo) Authorization line Infusions All other tests auth required ONLY if the diagnosis does not meet medical criteria *Medical Management: listed in the medical bulletin online *Infusions: , Echos, Nuclear Medicine, Echos NIA (National Imaging Associates): , Echos, Nuclear Medicine Care Core National: *** (Authorization guidelines are based on the state the patients PCP resides. Example: if a patient has a Mass HMO policy with a NH PCP the Mass policy will follow NH guidelines for pre authorization see NH guidelines below *** *Authorization is required as secondary to Medicare *If AIM states auth is not thru them: auth will be required thru Medical Management for MA/NH/ME based on location of the PCP -Mass Medical Management New Hampshire Medical Management Maine Medical Management *Infusions call Mass Medical Management directly *Sleep Studies require auth thru AIM eff:6/1/13 *Inform the patient they cannot bring in their own medication they may need to give Express Scripts permission to set up delivery with WDH pharmacy. Click on Providers - then click Medical Policies - Enter the medical policy number for one of the following: CT/CTA MRI/MRA Breast MRI PET Nuclear Stress Ultrasound 007 *NIA Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) *For any tests other than those listed call the health plan directly *Obtain tracking # or reference # if representative states no auth required BC of NH (NH Exchange policies) (Prefixs YGB & YGM exempt as secondary to Medicare), Echos, Sleep Studies, Sleep PSG w/mslt, EEG Video 95951, Infusions *Imaging//Sleep/Nuc Cardio AIM (American Imaging Management): *Infusions & Sleep PSG w/mslt (cpt 95805,) Medical Management: *When AIM states patient is not in their system: call Medical Management@ to verify who to obtain authorization from. If Medical Management states auth is still required thru AIM Medical Management will initiate a 3 way call with AIM to add the patient back into AIM's system so authorization can be obtained. *Authorization is required when secondary to ANY other insurance policy including Medicare. *NHN policies with a Maine PCP go thourgh Medical Management *NH Exchange polices follows the same guidlines as BC of NH.

4 BC of North Carolina, Echos, Echos BC of NY BC of NY (Empire) *Prefix YLA exempt when 2nd to Medicare *Prefix YLS follows United HealthCare Guidelines see below, Echos BC of NY (Excellus) BC of Pennsylvania (Highmark) BC of Pennsylvania (Independence) BC of Rhode Island BC of South Carolina (prefix INE included) BC of Tennessee BC of Vermont MRI/MRA, CT/CTA, PET Nuclear, Infusions, Echos, Sleep Studies, Infusions NIA (National Imaging Associates): *CareCore National: *Infusions: *NIA (National Imaging Associates): *Health Plan: * *Health Plan: or # on back of ID card, Echos MSI (Med Solutions): *NIA (National Imaging Associates): *Health Plan: MSI (Medsolutions): MRI/MRA, CT/CTA, PET, Sleep Studies *If AIM states "not required", they will advise you to call the health plan to check for any other auth requirements *For any tests other than those listed call the health plan directly *NIA Authorizes all 3 levels of contrast with, without and with and without *For any tests other than those listed call the health plan directly *Some policies may not require authorization provide the # you called along with the date, time, and name of representative that provided that information. *Obtain reference # from Care Core National representative if stated authorization is not required. *For any tests other than those listed call the health plan directly to verify authorization requirements. *Authorization requirements are policy specific- if NIA states not authorization required through them call the health plan to verify *For Sleep Studies call the health plan *If AIM states auth is not required call the health plan and skip the imaging prompt (if you select the imaging prompt you will be routed back to AIM) *Copy and Paste the following link to see additonal tests that require auth (updated regularly): roval/ibc_precert.pdf *MSI does not authorize all 3 levels of contrast- Authorizations are CPT code specific. *If NIA states the patient is not in their system call the health plan@ or # on back of patients card to verify pre-cert requirements. *For any tests other than those listed call the health plan directly to verify authorization requirements. *Sleep Studies get authorization request form - Click Provider, then Provider Forms then View Forms click Prior Approval Request & Referral Authorization Form for Medical Services *For any tests other than those listed call the health plan directly to verify authorization requirements.

5 BC of Virginia BC of WA (Premera) BC of Wisconsin BC/BS Regency Group Breast & Cervical Cancer Program MRI/MRA, CT/CTA, PET, Echos, Nuclear Medical Management: MRI/MRA, CT/CTA, PET, Echos, Nuclear MRI/MRA, CT/CTA, PET, Echo's, Nuclear, Echos, Infusions Regence Group Administrators: Phone: Fax: *Plan specific - call Medical Management on all tests *AIM Authorizes all 3 levels of contrast with contrast without contrast and with and without contrast *AIM Authorizes all 3 levels of contrast with contrast without contrast and with and without contrast *For any tests other than those listed call the health plan directly to verify authorization requirements. *Elective procedures need prior authorization *Emergent procedures can be done and auth obtained at later date. Capitol District Physicians Health Plan Everything at WDH requires authorization Phone: WDH is out of network with this plan and will need authorization even if the cpt code does not itself need auth. Please obtain auth based on being out of network. *Card states: Certification is mandatory for all hospital confinement or outpatient procedure Celtic All Outpatient or # on card ChampVA n/a n/a Auth is not required as out patient. Cigna ConnectiCare Coventry Health Definity Health MRI/MRA, CT/CTA, VTI (CPT 77011), PET, Nuclear Cardio, Bone length, Infusions, Sleep Studies (For at home sleep tests please auth not G0399) **Echo's require medical necessity review (pages in the medical policy are the "Not Covered" codes) EFFECTIVE 2/17/14 Stress Echos and Diagnostic Heart Cath, Nuclear Medicine Call # on Card *Medsolutions (MSI) for imaging & nuclear studies: *Cigna direct phone for CT VTI CPT & Infusions: *CareCentrix phone for all sleep studies: Fax: or Cigna.SleepCCX.com NIA (National Imaging Associates): *Use the Cigna master precert list online mycignaforhcp.com for auth requirements for all tests other than Imaging & Nuc Cardio or call Cigna directly *VTI cpt code requires auth thru Cigna directly *Sleep Studies thru CareCentrix eff: February 18, 2013 when requesting authorization for an at home sleep study please use code no G0399. NON-EMERGENT SERVICES ARE NOT COVERED AT WDH *NIA Authorizes all 3 levels of contrast *For any tests other than those listed call the health plan directly EBPA Infusions Health Plan: Auth is not required as secondary to Medicare Medsolutions (MSI): *PPO and Mass Health policies require precert directly MRI/MRA, CT/CTA, PET Health Plan: through Fallon at Fallon Federal Blue Cross (prefix R) n/a n/a Auth is not required as out patient.

6 GEHA GHI Great West Healthcare, Echos Exempt Medsolutions (MSI): Care Core National: Medsolutions (MSI): *Auth is not required as secondary to Medicare *TIP-GWH plans w/the Cigna logo - look the patient up on MSI under Cigna Harvard Pilgrim (HPE & HPK exempt) HCVM HMA Admin Health America (Coventry) Health Net Health New England, Infusion, Sleep Studies, CPAP, Nuclear Medicine, Biopsies exempt *Medical necessity review is required for all Echo's, Nuclear & Gastric Emptying Scan *NIA (National Imaging Associates): *CareCore National for Sleep Studies& CPAP: or # on card NIA (National Imaging Associates): , Stress Echo, SPEC MRI/MRA, CT/CTA, PET, Angio, Nuclear First Health: MSI (MedSolutions): *Authorization is also required as a secondary insurance including 2nd to Medicare *Sleep Studies Require auth thru CareCore Sleep Actigraphy is not a covered test *Authorizations for CPAP(94660) can only be done after the sleep study has been preformed. *All Echo's,Gastric Emptying Scans (cpt: 78264) and Nuclear Cardio studies must meet HP's Medical policy *MSI does not authorize all 3 levels of contrast Authorizations are CPT code specific directly to verify authorization requirements. Health Plans Inc Health Plans Dirigo-(prefix HHD only) Health Plans - WDH employees (HHAC4) Sleep Studies & CPAP follow up, Cath/Angio procedures, Infusions All other test are plan specific call Care Management on each patient Medical necessity review is required for Echo's Care Management: MRI/MRA, CT/CTA, PET, Cath/Angio, Nuclear, Sleep Studies *Imaging & Nuc Cardio call NIA (Naitonal Imaging Associates): *For all other testing call Dirigo Directly: All Sleep Studies & CPAP follow up, Cath/Angio procedures, Infusions Medical necessity review is required for Echo's Care Management: *CPAP follow up (CPT94660) can be added to the original sleep study authorization *All Echo's,Gastric Emptying Scans (cpt: 78264) and Nuclear Cardio studies must meet HP's Medical policy. directly to verify authorization requirements. *NIA authorizes all 3 levels of contrast with contrast without contrast and with/without contrast *For any tests other than those listed call the health plan directly to verify authorization requirements. *CPAP follow up (CPT94660) can be added to the original sleep study authorization *All Echo's,Gastric Emptying Scans (cpt: 78264) and Nuclear Cardio studies must meet HP's Medical policy *For any sleep study for WDH Health Plans with a Sleep Diagnosis authorization is required, if the respresentative states no authorization is required please ask them to double check.

7 Humana & Humana Gold MRI/MRA, CT/CTA, PET, Echos, Nuclear, Cardiac Cath, Nuclear Medicine, Sleep Studies Health-Help Imaging call All other medical services call Medical Keystone Mercy All Hospital Services Magna Care Sleep Studies, Pain Management Mail Handlers Must verify if the patients specific plan has out of network benefits as WDH is considered out of network with Humana NIA authorizes all 3 levels of contrast (w/o with w/wo) WDH Provider ID #: (Authorization is required as a secondary insurance to commercial payers; not Medicare.) Auth is CPT code specific Infusions, Effective March 1 for ages 21-64: CT, PET Out-patient diagnostic testing authorizations are not required as WDH is considered an "in state" facility All patients do not have the same plan w/mainecare Please call on Infusions as they are plan specific - include the reference # on the order. For any CT/PET request you can start submit to MaineCare Feb 3. MaineCare Maine Community Health Options (MCHO) Infusion Fax: Submit all notifications via completed form on MCHO online. Martin's Point/US Family Diabetes, Dietary, Angio, Rehab Services including pulmonary, Infusions, anything invasive (procedures including biopsies/pic lines, needle aspiration, etc.), Rad-only tomogram injection Out-patient Diagnostic authorizations are no longer required p/auto line Medicaid - New Hampshire (Please be aware all spend-down patients will not be a part of the managed care plans, these patients guidelines for authorization will not change), Infusions MRI/MRA, CT/CTA, Nuclear Cardio Imaging, PET Scans, Cardiac Event Monitors(Holter Monitors Exempt), Well Sense- NHCaid Eff:12/1/2013 Infusions, Sleep Studies, EEG w/cpt (Authorization REQUIRED 2nd to 95951, Echos/Stress Echos, Medicare) Ultrasound Exempt eff: July 1, 2013 fax all auth requests to Kepro F: P: Med Solutions: Prior Authorization: Pharmacy: option 4&2 (Authorization is required as a secondary insurance to commercial payers; but not required as 2nd to Medicare or Medicare Replacement plans) Dietary consults are not a covered benefit. Authorizations can take at least 48 business hours to process. Status inquires on Schaller Anderson & Kepro authorization: call Xerox P: Contact Med Solutions for any imaging requests. Contact the Prior Authorization line for any other outpatient services. When requesting an outpatient authorization from the Health Plan (not MSI) please request a date range, if a date range is not requested only one date of service will be approved. When requesting authorization for infusion please verify through the Prior Auth line and the Pharmacy line. NH Healthy Families- NHCaid Eff:12/1/2013 (Authorization REQUIRED 2nd to Medicare) MRI/MRA, CT/CTA, Nuclear Cardio, Nuclear Imaging, PET Scans, Infusions, Sleep Studies Ultrasound Echos NH Healthy Families: NIA(National Imaging Associates): Please use the Prior Authorization Tool to determine whether authorization is needed for all other services.

8 Meridian Health Plan- NHCaid Eff:12/1/2013 Medicare Meritain Health (HCVM) MVP Healthcare MRI/MRA, CT/CTA, Nuclear Cardio, Nuclear Imaging, PET Scans, Infusions, Home Sleep Studies, Biospies, EEG Video w/cpt Meridian Health Plan: Medical Necessity check on the NGS Medical Necessity Review is required website American Health Holding or American Health Group or Total , Sleep Studies, Infusions MVP: CareCore National: Sleeps: Call SMS x121 or website NALC Medsolutions (MSI) Neighborhood Health MRI/MRA, CT/CTA, PET New Hampshire Health Plans Health Plan : (NHHP) Infusions Auth: Northeast Community Care - Arcadia (Medicare Replacement Plan) Authorization is required for everything including lab work Oxford Health Plans Plan specific Phone # provided on insurance card Nuclear Cardio, Nuclear Medicine, Patient Advocates Infusions Contact Health Plan directly for authorization inquiries. See Meridian Prior Authorization Procedures Overview on their website under Provider Manualhttp:// vider&page=home No authorization required when 2nd to Medicare Auth not required but all outpatient Plan specific - Auth could be thru any one of the companies listed Sleep Study auth's thru SMS Effect 04/01/2012 Imaging authorizations are thru CareCore National ** You will need to manually added the rendering site giving the WDH address and phone # during the authorization process until further notice** Auth is not req as secondary to Medicare MSI does not authorize all 3 levels of contrast - Authorizations are CPT code specific Part of the Cigna network - look up online or by phone as if it s a Cigna plan All other testing is not required as out patient. Non-urgent authorizations can take up to 14 business days. Urgent authorizations can take 3-4 business days. Verification of benefits/coverage is needed to see if WDH is in network. Out pt diagnostic auth not req unless "Nuclear" is involved in the test Patriot Healthcare Presbyterian HealthCare Services The Empire Plan Today's Options (PFFS plans exempt) TriCare Prime/Standard - TriCare Health net (TriCare for Life exempt), Endo, Cardiac Rehab, Pain Management after 3 visits All other tests call the health plan directly Imaging pre-cert call: Health Health Plan Auth not required as secondary to Medicare Pain, Endo, All other diagnostic tests are plan specific (ie: CT/MR/Sleep ) Care Core National: Today's Options: or online If CareCore States auth is not required -Call the health plan to make sure they don t require it directly thru them. Call health plan directly on all other test as it may require auth. ALL forms of TriCare require authorization verification except TrCare for Life. Call or go online prior to scheduling.

9 Tufts Carelink Tufts Health Plan UMR Unicare United Healthcare, Medicare Complete/Solutions, Secure Horizons (PFFS plans exempt) INCLUDE ID# & GROUP# ON ORDER Policy specific, you may need to call # on back of card to find out if auth is thru Medsolutions or Cigna MSI, Sleep Studies, Infusions Cigna or Medsolutions (MSI) Sleep Studies thru CareCentrix - eff: February 18, 2013 does not authorize all 3 levels of contrast (w/o with w/wo) - Authorizations are CPT code specific CareCentrix p f or Cigna.SleepCCX.com, Infusions NIA or # on Card NIA authorizes all 3 levels of contrast (w/o with w/wo) You will need to obtain a benefits fax before you are able to speak with a representative. The fax will also tell you if authorization is required for Outpatient tests or # on the back of the All tests are plan specific card MRI/MRA, CT/CTA, Nuclear, Echo's or # on card Not required as secondary to Medicare, Nuclear Medicine, CATH, Infusions, Sleep Studies, Echo's *biospies exempt UHC also has Echo medical policy to check for medical necessity US Department of Labor All tests need approval VA Medical (NH) All tests need approval CareCore National Cardio/Imaging/Nuc Med call Health Plan Alternate Group # is required for pre-cert inquiries United Healthcare: Authorization is REQUIRED as secondary to Medicare (UHC group # exempt) AARP Medicare Complete/Solutions/Secure Horizons are policy specific - call on each plan. Options on the Cardio/Imaging/Nuc Med line have changed - please listen carefully Obtain ref/case # when a case has been started and turns out that auth is "not required". UHC does not authorize all 3 levels of contrast; Authorizations are CPT code specific Sleep Studies & Infusions are plan specific call Health Plan directly Call to verify correct date of injury (DOI) that matches the correct injured area/body part and if authorization is required. You will need the patients claim # or social security # with the DOI in order to obtain information or auth. Workman's Compensation All tests need approval Call adjuster or nurse case manager at the W/C Insurance Company Call to verify correct date of injury (DOI) that matches the correct injured area/body part. Ask adjuster or nurse case manager if the claim is open, on file and if authorization is required. W/C Claims w/patients working in the state of NH generally do not require authorization. Always obtain authorization from the patients medical insurance as back up incase the W/C Claim is denied. 4/24/14 KB Call and ask for a Pre-cert Representative for any/all questions