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AetnaNew York Physical Medicine Overview for Providers
Aetna Physical Medicine Overview
What:
When:
Who:
• Aetna will initiate a Utilization Management Prior Authorization Program for outpatient Physical Medicine Services
• All provider types will be required to obtain an authorization for identified Physical Medicine Codes
• The program includes both rehabilitative and habilitative care
• Program Start Date: September 1st, 2018
• Aetna New York • Includes all members except ASO and Out of
Network Services
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Our Program
• Prior Authorization Process and Overview
• Clinical Information Required
• Notification of Determination
• Provider Network
• Claims
• Provider Tools and Contact Information
• Questions & Answers
NIA Physical Medicine Program Agenda
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A Unique Vision of Care
>20% clinical disapproval
rates
As the nation’s leading specialty health care management company, we deliver comprehensive and innovative solutions to improve quality outcomes and
optimize cost of care.
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NIA Facts
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NIA Facts
NIA Facts
• Providing Client Solutions since 1995
• Magellan Acquisition (2006)
• Headquartered in Scottsdale, AZ
• Business supported by two National Call Operational Centers
Industry Presence
• 78 Health Plan Clients serving 27.06 National Lives
• 15.57M Commercial;
• 1.45M Medicare;
• 10.04M Medicaid
• 41 states
Clinical Leadership
• Strong panel of internal Clinical leaders – client consultation; clinical framework
• Supplemented by broad panel of external clinical experts as consultants (for guidelines)
Product Portfolio
• Advanced Diagnostic Imaging
• Cardiac Solutions
• Radiation Oncology
• Musculoskeletal Management (Surgery/IPM)
• Physical Medicine (Chiropractic Care, Speech Therapy, Physical and Occupational Therapies)
• Provider Profiling & Practice Management Analysis
Prior AuthorizationProcess and Overview
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NIA’s Physical Medicine Prior Authorization Program
Effective September 1, 2018, Aetna will begin partnering with NIA for themanagement of Physical Medicine Services. The NIA Call Center will be availablebeginning August 27, 2018 for prior authorization for dates of service September 1,2018 and beyond. Any services rendered on and after September 1, 2018 will requireauthorization.
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*Code list available online at www.RadMD.com and www.aetna.com/physicalmedicine
Services Requiring
Authorization
• Outpatient Physical Medicine Codes*• Provider types that commonly use these codes
include, but are not limited to Physical Therapists, Occupational Therapists, Chiropractors, and Physicians
Excluded from Program
• Hospital ER, Inpatient, and Observation Status• Acute Rehab Hospital Inpatient• Skilled Nursing Facility• Home Therapy
Physical Medicine Services Requiring Prior Authorization
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Evaluation codes do not require authorization. Only specified codes require authorization.
CPT Code Description97012 Mechanical Traction Therapy97014 Electric Stimulation Therapy97016 Vasopneumatic Device Therapy97018 Paraffin Bath Therapy97022 Whirlpool Therapy97024 Diathermy Treatment97026 Infrared Therapy97028 Ultraviolet Therapy97032 Electrical StimulationG0283 Electrical StimulationS8948 Low Level Laser97033 Electric Current Therapy97034 Contrast Bath Therapy97035 Ultrasound Therapy97036 Hydrotherapy97039 Unlisted Modality (Specify)97110 Therapeutic Exercises97112 Neuromuscular Reeducation97113 Aquatic Therapy/Exercises97116 Gait Training Therapy97124 Massage97139 Unlisted, Therapeutic Procedure 97140 Manual Therapy97150 Group Therapeutic Procedures97530 Therapeutic Activities
CPT Code Description
97127 Cognitive Skills Development
G0515 Cognitive Skills Development
97533 Sensory Integration
97535 Self-Care Management Training
97542 Wheelchair Management
97750 Physical Performance Test
97760 Orthotic(s) Management, Initial Encounter
97761 Prosthetic Training, Initial Encounter
97763 Orthotic/Prosthetic, Subsequent Encounter
98925 Osteopathic Manipulative Treatment (OMT), one or two body regions
98926 OMT, three to four body regions
98927 OMT, five to six body regions
98928 OMT, seven to eight body regions
98929 OMT, nine to ten body regions
98940 Chiropractic Manipulative Treatment (CMT), one or two spinal regions
98941 CMT, three or four regions
98942 CMT, five regions
98943 CMT, extraspinal, one or more regions
Physical Medicine CPT Codes Requiring Prior Authorization with Allowable Billed Groupings
Parent CPT Code*
Description Allowable Billed Groupings*
98940 MANIPULATION 98940, 98941, 98942, 98943, 98925, 98926, 98927, 98928, 98929
97110 ACTIVE PROCEDURES 97110, 97112, 97113, 97116, 97150, 97530
97535 SELF CARE, COGNITIVE, SENSORY SKILLS
97127, G0515, 97533, 97535, 97542
97140 MANUAL INTERVENTIONS 97124, 97140
97035 MODALITIES 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97139, G0283, S8948
97760 ORTHOTIC/PROSTHETICS 97760, 97761, 97763
97750 PHYSICAL PERFORMANCE TEST 97750
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*Parent CPT code is the code that will appear on the authorization with the allocated number of units. Provider may bill the allowable grouped codes as appropriate under that authorization.
Responsibility for Prior Authorization
*Failure to obtain an authorization may result in denied claims. **NIA recommends that you do not schedule any additional physical medicine services beyond the initial evaluation until authorization is obtained.
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Provider Responsibilities
Verify member’s benefits by contacting Aetna’s Customer Service Department.
Obtain an authorization for physical medicine services prior to rendering and/or within 5 business days of the evaluation if services were rendered during the evaluation or prior to requesting an authorization*
Ensure that prior authorization has been obtained prior to rendering services beyond the evaluation (or within the permitted timeframe)**
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Patient Benefits
• Providers will be instructed to confirm Member’s benefits as well as benefit limitations through the Aetna’s Customer Service Department prior to submitting an authorization.
• Member benefits are in visits per year
• Each date of service is calculated as a visit
• Aetna keeps track of how many visits per year is used
• Office/Facility should verify benefits and visits available for each member
• Aetna’s claim edit will cap payment at 4 units or 60 minutes of treatment per day
Units• NIA will manage authorizations in units
• NIA follows Medicare rules for reporting timed units. Billing units are based on 15 minutes per unit for time based codes
• Units will be used each visit for patient care
• Authorizations will include a specified number of units based on service and patient’s medical condition
• Office/Facility will keep track of units and use them accordingly
• Additional units can be requested by uploading supportive clinical documentation or faxing to NIA
Authorization Process Overview
Log in to RadMD or call NIA’s Call Center prior to OR within 5
business days of rendering the
service.
Clinical Algorithm
www.RadMD.com
Algorithm
Provider Performs Service
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Prior Authorization Process
After the evaluation has been completed*
and/or a plan of care established, request authorization for the services/codes to be
rendered.
*Evaluation codes do not require authorization
Claim
Treatment may be authorized
and/or you may be instructed to submit clinical for validation
upon completion of the evaluation.
Documentation Submitted,
Reviewed and Decision
Rendered
Clinical InformationRequired
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• Clinical guidelines are reviewed and mutually approved by Aetna and NIA Chief Medical Officers and senior clinical leadership.
• NIA’s algorithms and medical necessity reviews collect key clinical information to ensure that Aetna’s members are receiving appropriate outpatient rehabilitative and habilitative physical medicine services.
• NIA issues authorizations in accordance with Aetna’s benefit guidelines, NIA internally developed guidelines, commercially licensed guidelines and Apollo Licensed Guidelines for physical medicine services.
• NIA Clinical Guidelines are available on www.RadMD.com : • Select the Solutions tab at the top of the page• Click on Physical Medicine to be directed to the general guidelines page
• To access Aetna’s specific criteria online at www.RadMD.com :• Sign In with User name and passcode• At Menu Options, click link to Clinical Guidelines• Click on the “Health Plans” selection on the menu bar. • Scroll down the page to locate your specific health plan name • Click on the link to open the pdf document.
Clinical Decision Making and Algorithms
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Patient and Clinical Information Required for Authorization
*Refer to the Clinical records checklist on RadMD for more specific information
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GENERAL INFORMATION AT INTAKE
• Provider information and type, member information, date of initial evaluation, types of service codes requested.
CLINICAL INFORMATION AT INTAKE
• Treating Diagnosis and body region being treated, date of onset. Surgery date and procedure performed (if applicable)
• Brief medical history and summary of previous therapy (if any)
• Functional Outcome Tool and Scores; Level of Impairment
CLINICAL RECORD CONTENT *NEEDED FOR CLINICAL VALIDATION
• Baseline evaluation including current and prior functional status
• Objective tests and measures appropriate to the discipline of therapy, standardize test with raw score, functional outcome assessments and scores
• School programs, including frequency and goals (for habilitative services)
• Treatment prognosis and rehab potential.
• Treatment Plan including interventions planned , specific functional goals that are measurable, sustainable and time-specific
NIA to Provider: Request for Additional Clinical Information
• A fax is sent to the provider detailing what clinical information that is needed, along with a Fax Coversheet
• We stress the need to provide the clinical information as quickly as possible so we can make a determination
• Determination timeframe begins after receipt of clinical information
• Failure to receive requested clinical information may result in non-certification
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Submitting Additional Clinical Information/Medical Records to NIA
• Two ways to submit clinical information to NIA
− Via RadMD Upload
− Via Fax
• Use the Fax Coversheet (when faxing clinical information to NIA )
• Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call Center @ 1- 866-842-1542
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Be sure to use the NIA Fax Coversheet for all transmissions of clinical information!
Prior Authorization Process
Intake Level Initial Clinical Review
• Requests are evaluated using our clinical algorithms
• Requests may:
1.Approve
2.Require additional clinical review and Pend for clinical validation of medical records
• Peer reviewer (therapist, chiropractor, physician, etc.) will review request and may:
1.Approve
2.Deny
• Occurs beyond the initial authorization
• Requests can be made by uploading records on RadMD or faxing in the request using the fax coversheet provided with the initial authorization
Subsequent Requests
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A peer to peer discussion is always available!
Subsequent Requests
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• If additional units are requested , a new type of intervention (new billable grouping) or date extension is needed, clinical validation is required
• Request can be made via RadMD or Fax using previously provided fax coversheet or print a new one
• A new request is not necessary. It is considered an update to the existing authorization.
Service Authorized with Number of Units and Validity Period
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Service Dates: Procedure Code: Service Description: Number:
09/01/2018 –
12/01/2018
97110 Active Procedures 6
09/01/2018 –
12/01/2018
97035 Modalities 6
09/01/2018 –
12/01/2018
98940 Manipulation 12
Service Dates: Procedure Code: Service Description: Number:
09/01/2018 –
10/01/2018
97110 Active Procedures 6
09/01/2018 –
10/01/2018
98940 Manipulation 4
Service Dates: Procedure Code: Service Description: Number:
09/01/2018 –
11/01/2018
97110 Active Procedures 12
09/01/2018 –
11/01/2018
97035 Modalities 4
09/01/2018 –
11/01/2018
97140 Manual Interventions 4
09/01/2018 –
11/01/2018
97760 Orthotics/Prosthetics 2
Peer to Peer Reviews
• A peer reviewer may reach out during the review process to discuss the plan of care and/or treatment interventions being utilized. This may or may not be in the face of any adverse determination, but allows reviewers to gain insight into the providers’ clinical judgement and/or discuss any deviations from evidence based practice.
• A formal peer-to-peer, with one of our specialty matched peer reviewers, is offered in the face of any adverse determination recommendation, prior to finalizing the denial. NIA will reach out to the provider via phone and fax to offer them an opportunity to discuss this case and/or submit additional clinical information that was not previously reviewed.
• If the provider is not able to conduct a Peer to Peer at the time NIA reaches out, they may schedule one at a more convenient time by calling NIA at 1- 866-842-1542.
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Summary Physical Medicine Points
• Only specified codes require authorization, evaluation codes are NOTincluded in this list of codes.
• Authorization is required for all provider types billing these physical medicine codes
• If multiple provider types are requesting services, they will each need their own authorization (i.e. PT and OT services)
• The requestor will be asked a series of questions to determine if clinical validation is required or if an authorization can be issued immediately
• All subsequent requests require clinical validation. Providers can either upload or fax this information for review
• An authorization will consist of a billable grouping, number of units for each approved grouping and a validity period.
• Authorizations will be issued using a parent code to allow flexibility in the provider’s treatment plan. Providers must bill the appropriate code that matches the actual services rendered
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Notification of Determination
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Validity Period and Notification of Determination
• Authorizations will include the type and volume of codes approved and a validity period with which to use those codes in
• If additional codes (volume or service type) are needed, a subsequent request must be submitted
• The approval notification will include a fax coversheet that can be used for any subsequent requests
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• Notifications will include an explanation of what services have been denied and the clinical rationale for the denial
• A peer to peer discussion will always be offered prior to issuing an adverse determination
• A reconsideration time frame may be available and can be initiated by a peer discussion or by submitting additional clinical information
• Information on how to proceed with a complaint or appeal will be included in the notification
Approval Notification Denial Notification
Network
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Provider Network and Benefit Structure
• Provider Network: • Aetna’s network of providers including Therapists, Chiropractors and
Physicians will be used for the Physical Medicine Program.
• Benefit Structure: • This Physical Medicine Program does not impact the current benefit structure
including any covered services exclusions or benefit limits.
• Please reference the Provider and Member Manuals for additional information or contact Aetna’s Provider Service Department for any Benefit questions.
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Claims
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How Claims Should be Submitted Claims Appeals Process
• Providers will continue to submit their claims to Aetna
• Providers should not submit claims until after an authorization is obtained to avoid denial of payment for non-authorization
• Providers are strongly encouraged to use EDI claims submission
• In the event of a prior authorization or claims payment denial, providers may appeal the decision through Aetna
• Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification.
Processing of Claims
Provider Tools andContact Information
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Provider Tools
Toll free authorization and information number 1- 866-842-1542
Available 8:00 a.m. – 8:00 p.m. EST
• Interactive Voice Response (IVR) System for authorization tracking
RadMD Website – Available 24/7 (except during maintenance)
• Request authorization and view authorization status
• Upload additional clinical information
• View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents
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Registering on RadMD.comOrdering Provider:
STEPS:
1. Click the “New User” button on the right side of the home page.
2. Select “Physical Medicine Practitioner”
3. Fill out the application and click the “Submit” button.
− You must include your e-mail address in order for our Webmaster to respond to you with your NIA-approved user name and password.
NOTE: On subsequent visits to the site, click the “Sign In” button to proceed.
1Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations.
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3
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Offices that will be both ordering and rendering should request ordering provider access this will allow your office to request authorizations on RadMD and see status of those authorization request.
Rendering Provider:
STEPS:
1. Click the “New User” button on the right side of the home page.
2. Select “Facility/office where procedures are performed
3. Fill out the application and click the “Submit” button.
− You must include your e-mail address in order for our Webmaster to respond to you with your NIA -approved user name and password.
NOTE: On subsequent visits to the site, click the “Sign In” button to proceed.
IMPORTANT
• Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations.
• Designate an “Administrator” for the facility who manages the access for the entire facility.
1
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3
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If you have multiple staff members entering authorizations and you want each person to be able to see all approved authorizations, they will need to register for a rendering username and password. The administrator will have the ability to approve rendering access for each employee. This will allow users to see all
approved authorizations under your organization.
Dedicated NIA Provider Relations Manager for Aetna Providers:
Aetna New York:
NIA Dedicated Provider Relations Manager: Charmaine Gaymon-Everett
Phone: 1-800-450-7281, ext. 32615
Email: [email protected]
Aetna Physical Medicine Project Lead: Shiron Hagens
Email: [email protected]
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Confidentiality Statement
The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to NIA members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health Services, Inc.
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