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HealthPlus Amerigroup Provider Training Program
Provider Training Program Agenda
• Welcome and Opening Remarks • About NIA • The Provider Partnership • The Program Components • How the Program Works:
– The Authorization Process o The Authorization Appeals Process
– The Claims Process o The Claims Appeals Process
• Provider Self-Service Tools (RadMD and IVR) • RadMD Demo • NIA Provider Relations and Contact Information • Questions and Answers
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National Imaging Associates (NIA)
About NIA
• National Imaging Associates (NIA) – chosen as the solution for national and regional health plans covering more than 17 million lives due to: o Distinctive clinical focus o NCQA accreditation and URAC certification o Innovation and stability from parent company, Magellan Health
Services, which: – Enhances operational competencies, IT capabilities and patient
support tools – Affords financial stability for growth and continued investment in
innovative technology
• Focus/results: Maximizing diagnostic services value and promoting patient safety through: o A clinically driven process that safeguards appropriate diagnostic
treatment for HealthPlus Amerigroup members
NIA is accredited by NCQA and is URAC-certified
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The NIA Partnership Model
• Dedication to provider service and convenience o Dedicated provider relations staff o Authorization call center o Interactive Voice Response (IVR) o Education and training programming o Ongoing outreach to providers
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Outpatient Imaging Program Components
Prior Authorization/ Utilization Management
NIA's proprietary, evidence-based decision support algorithms support scripting for call center representatives or online — leading to quick procedure approval or consultation with our radiology experts.
Information and Transaction Tools
Our website, RadMD.com, provides the ability for ordering providers to request and obtain authorizations, reference lists of nearby imaging facilities, locate authorizations given, and gain rapid authorization requests. Providers report a high level of satisfaction with their use of RadMD, finding it a simple tool to use and a time-saver for staff.
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The Authorization Process
• Nonemergent outpatient: o CT /CTA o MRI/MRA o PET scans o Nuclear cardiology
• Any code specifically cited in the HealthPlus Amerigroup/NIA Billable CPT Codes Claims Resolution Matrix handout
The CPT Claims Resolution Matrix is available on www.RadMD.com. All other procedures will be authorized and paid by HealthPlus Amerigroup per their payment policy.
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NIA Prior Authorization is required for:
• Emergency room, urgent care centers, inpatient and observation: o CT /CTA o MRI/MRA o PET scans o Nuclear cardiology
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NIA Prior Authorization is not required for:
NIA Clinical Expertise and Provider Engagement NIA reviews more than 450,000 advanced
imaging provider requests each month.
Algorithms and guidelines are reviewed and mutually approved by the HealthPlus Amerigroup and NIA Chief Medical Officers.
Many NIA algorithms recommend substituting more costly but more effective imaging technology. Our goal – the most appropriate test early in an episode of care for HealthPlus Amerigroup members.
Clinical consultation is a hallmark of NIA – we have 86 board-certified physicians representing radiology and a host of other specialties available for physician-to-physician (peer-to-peer) discussion.
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Physicians’ office contacts NIA for prior authorization of study
Clinical information complete – procedure
approved
Clinical information not complete –
additional information needed
System evaluates request based on physician entered information
Request for specific clinical
information needed
Additional clinical information complete
– procedure approved
Additional clinical not complete or
inconclusive
Nurse/Clinical Specialty Team Review
Physician approves
case without peer-to-peer
Physician approves case with
peer-to-peer
Physician denies case
Physician Review
Ordering physician withdraws case W
92% of all cases receive final determinations in 24 – 48 hours.
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NIA Clinical UM Authorization Process
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• The ordering physician is responsible for obtaining prior authorization.
• The rendering provider must ensure prior authorization has been obtained, and it is recommended that you not schedule procedures without prior authorization.
• Procedures performed without proper authorization will not be reimbursed.
• If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed, please contact NIA immediately with the appropriate clinical information for an expedited review. The number to call to obtain a prior authorization is 1-800-642-7565.
• If an emergency clinical situation exists outside of a hospital emergency room, please contact NIA immediately with the appropriate clinical information for an expedited review. The number to call to obtain a prior authorization is 1-800-642-7565.
• Separate prior authorization numbers are not needed for CT-guided biopsy, CT-guided radiation therapy and some MR-guided procedures.
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NIA Authorization Process
NIA OCR Fax Cover Sheet – Submission of Clinical Information
• NIA does not accept faxes for initial authorization requests. • NIA utilizes OCR technology which allows us to attach the clinical
information that providers send to be automatically attached to an existing prior authorization request.
• For the automatic attachment to occur, providers must use the NIA Fax Cover Sheet as the first page of the fax.
• Providers can obtain an NIA Fax Cover Sheet in the following ways: o If submitting a prior authorization request online through RadMD, at the end of the
submission, the provider is given the option to print the cover sheet. – On RadMD, click on Request a Fax Cover Sheet. This will allow the provider to
print the cover sheet for a specific patient. o By calling the NIA Clinical Support Department at 1-888-642-7649, providers can
request that a cover sheet be faxed to them. o If we have sent a fax requesting additional clinical information, the NIA Fax Cover
Sheet should accompany the request. • Following this process will ensure a timely and efficient case review.
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Requests Pended for Clinical Review Upload clinical documentation or use Fax Cover Sheet
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The Authorization Appeals Process
The Authorization Appeals Process
• Appeals are processed by HealthPlus Amerigroup
• The ordering provider and member will receive verbal and written notification.
Medical Appeals HealthPlus, an Amerigroup Company P.O. Box 62429 Virginia Beach, VA 23466
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The Claims Process
How Claims Should Be Submitted
• Rendering providers/imaging providers should continue to send their claims electronically directly to HealthPlus Amerigroup
• HealthPlus Amerigroup payer ID numbers: o Emdeon: 27514 o Capario (formerly MedAvant): 28804 o Availity: 26375
• If unable to bill electronically, claims for HealthPlus Amerigroup members
should be submitted to: HealthPlus, an Amerigroup Company
P.O. Box 61010 Virginia Beach, VA 23466-1020
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The Claims Appeals Process
The Claims Appeals Process
• In the event of a prior authorization or claims payment denial, you
may appeal the decision through HealthPlus Amerigroup.
o Follow the instructions on your nonauthorization letter or Explanation of Payment (EOP) notification.
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Self-Service Tools and Usage
Multichannel Provider Relations Strategy
Radiology Provider
Interactive Voice Response
Internet Offerings • Initiate Authorization (Ordering Provider) • Authorization Inquiry
Provider Relations Staff • Provider Forums/Education • Centralized and Regional Support
IVR – Interactive Voice Response • Authorization Inquiry
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Self-Service Tools and Usage
• Interactive Voice Response (IVR)
o Use tracking number to check status of cases
• Website: www.RadMD.com
o Use tracking number to review an exam request
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NIA Website: www.RadMD.com
• Information concerning approved authorizations can be viewed at www.RadMD.com after login with username and password
• Providers may search based on the patient’s ID number, name or authorization number
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NIA Website: Imaging Facilities
• User-friendly, near-real-time Internet tool offered by NIA o Log on to www.RadMD.com
• Website offers access to:
o Member prior authorizations
– Date initiated
– Exam requested
– Valid billing codes (CPT)
o Helpful resources, including Clinical Guidelines for Radiology Procedures
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• Click the New User button on the right side of the home page.
• Fill out the application and click the Submit button.
• You must include your email address in order for our Webmaster to respond
to you with your NIA-approved username and password.
• Everyone in your organization is required to have his or her own separate username and password due to HIPAA regulations.
• On subsequent visits to the site, click the Login button to proceed.
To get started, visit www.RadMD.com
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NIA Contact Information
• NIA Provider Relations Manager: Charmaine Gaymon Phone: 410-953-2615 Email: [email protected]
• Provides educational tools to ordering and rendering providers on imaging processes and procedures.
• Liaison between HealthPlus Amerigroup Provider Relations and NIA.
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RadMD Demonstration
Questions & Answers
