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© 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.
Pre-Service Authorization of Medical Oncology Management for Banner Health NetworkProvider Orientation
Company Overview
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© eviCore healthcare. All Rights Reserved.This presentation contains CONFIDENTIAL and PROPRIETARY information.
Comprehensive Solutions9The industry’s most comprehensive clinical evidence-based guidelines
4k+ employees including 1k clinicians
Engaging with 570k+ providers
Ensure 100M* patients receive the right treatment at the right time for 25 years
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Headquartered in Bluffton, SCOffices across the US including:
• Melbourne, FL• Plainville, CT• Sacramento, CA
• Lexington, MA • Colorado Springs, CO• Franklin, TN• Greenwich, CT
Cardiology50M lives
Radiology70M lives
Musculoskeletal40M lives
Sleep16M lives
Post-Acute Care1.7M lives
Medical Oncology30M lives
Radiation Therapy39M lives
Lab Management19M lives
Specialty Drug723k lives
100 million lives
Integrated platform
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9 Comprehensive Solutions
Medical Oncology Solution - Our Experience
15+ Regional and National Clients
Members Managed• 25M+ Commercial membership
• 660K+ Medicare membership
• 3.7M+ Medicaid membership
400+ Casesbuilt per day
30M+ members managed nationwide
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10+ YearsManaging Medical Oncology Services
Service Model
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Enhancing outcomes through Client and Provider engagement
Enabling Better Outcomes
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Regional Provider Engagement Managers
Regional Provider Engagement Managers are on-the-ground resources who serve as the voice of eviCore to the provider community.
Client Experience ManagerClient Service Managers lead resolution of complex service issues and coordinate with partners for continuous improvement.
Client & Provider OperationsClient Provider Representatives are cross-trained to investigate escalated provider and healthplan issues.
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Why Our Service Delivery Model Works
One centralized intake point allows for timely identification, tracking, trending and reporting of all issues. It also enables eviCore to quickly identify and respond to systemic issues impacting multiple providers.
Complex issues are escalated to resources who are the subject matter experts and can quickly coordinate with matrix partners to address issues at a root-cause level.
Routine issues are handled by a team of representatives who are cross-trained to respond to a variety of issues. There is no reliance on a single individual to respond to your needs.
Our Clinical Approach
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Multi-Specialty Expertise
Clinical Staffing
Anesthesiology Cardiology Chiropractic Emergency MedicineFamily Medicine
• Family Medicine / OMT• Public Health & General Preventative Medicine
Internal Medicine• Cardiovascular Disease• Critical Care Medicine • Endocrinology, Diabetes & Metabolism• Geriatric Medicine • Hematology • Hospice & Palliative Medicine • Medical Oncology • Pulmonary Disease• Rheumatology • Sleep Medicine • Sports Medicine
Dedicated nursing and physician specialty teams for various solutions
Competency-Based Routing • Allows clinically complex cases to automatically route to a specific queue, based on clinical
specialty for review• Ensures greater accuracy of decision-making across the many clinical disciplines
800 Nurses with
diverse specialties / experience
>300 Medical Directors
Covering 51
different specialties
Radiology • Diagnostic Radiology• Neuroradiology • Radiation Oncology• Vascular & Interventional
Radiology Sleep MedicineSports Medicine Surgery
• Cardiac • General • Neurological• Spine• Thoracic• Vascular
Urology
Medical Genetics Nuclear Medicine OB / GYN
• Maternal-Fetal MedicineOncology / HematologyOrthopedic Surgery Otolaryngology Pain Mgmt. / Interventional PainPathology
• Clinical PathologyPediatric
• Pediatric Cardiology• Pediatric Hematology-Oncology
Physical Medicine & Rehabilitation Pain Medicine
Physical TherapyRadiation Oncology
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Continuallyupdated
Represents
97%of all cancers
Inclusive of
45cancer types
Our Medical Oncology Solution is Evidence Based
eviCore Guideline Management
National Comprehensive Cancer Network®
(NCCN)
26 of the World’s Leading Cancer Centers Aligned
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Auto-approve multidrug regimen
Health Plan and / or PBM
Medical Oncology Solution Defines a Complete Episode of Care
Treatment options may be modified to align with formulary
List of all NCCN treatment options
Select NCCN treatment regimen
Custom treatment regimen
eviCore Medical Oncology Guideline Management
Disease-Specific Clinical Information• Diagnosis at onset• Stage of disease• Clinical presentation• Histopathology• Comorbidities• Patient risk factors• Performance status• Genetic alterations• Line of treatment
Collect disease-specific clinical information
Select Disease
Clinical review
Authorize multidrug regimen
Not approved
Physician -to-
Physician
80unique attributes
Colon Cancer
>1,000possible traversals
45 NCCNtreatment regimens
2-5 minutes
to enter a complete
case
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Medical Oncology Pre-Service Authorization for Banner Health Network
Pre-service authorization requests will be accepted on June 25, 2019 for dates of services rendered on July 1, 2019 and beyond.
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Program Overview
Pre-Service Authorization applies to services that are:
• Outpatient• Elective/non-emergent
eviCore Pre-Service Authorization does not apply to services that are performed in:
• Emergency room• Inpatient• 23-hour observation
It is the responsibility of the ordering provider to request Pre-Service Authorization approval for services.
Applicable Membership
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Pre-Service Authorization is required for Banner Health Network members enrolled in the following programs:
• AARP Medicare Complete (UHC)• BCBS of Arizona Advantage Members
When requesting pre-service authorization for these members, please select Banner Health from the health plan dropdown list.
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Summary
What types of Drugs are included?
What is covered in my authorization?
How often do I need to update my
authorization?
• Primary Injectable Chemotherapy• Supportive Medications given with Chemotherapy
• All drugs that are included in the treatment regimen – there are no partial approvals.
• The HCPC codes associated with the approved drugs• The time period indicated on the authorization (8-14 months)• The Authorization is not for a specific dose or administration schedule.
However, billing in excess of the appropriate # of units or frequency of administration for a drug may result in claims denial.
• Supportive drugs will be issued as a separate authorization.
• When the authorization time has expired.• When there is a change in treatment including new or different
drugs.• NOT when dosing changes• NOT if an approved drug is no longer used
What about drugs billed through Pharmacy?
• The eviCore system will display oral drugs when used in an NCCN regimen in order to accurately describe the regimen, but those drugs will not be included in the authorization if the request is approved.
• Pharmacy drugs (typically orals) do not require PA through this program, but may require PA through the member's PBM. Please contact the PBM for additional information or instructions for drugs being billed under the pharmacy benefit.
• Drugs covered under this program, but being used to treat non-cancer conditions may require PA. Contact the number on the ID card to confirm requirements.
© eviCore healthcare. All Rights Reserved.This presentation contains CONFIDENTIAL and PROPRIETARY information.
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WEB
The eviCore online portal is the quickest, most efficient way to request prior authorization and check authorization status and is available 24/7. By visiting www.eviCore.comproviders can spend their time where it matters most — with their patients!
Or by phone:Phone Number:888-444-92617:00 a.m. to 7:00p.m.(Monday – Friday)
Pre-Service Authorization Process
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Trigger event
Visit provider
Clinical Decision Support
Nursereview
MD review
Appropriate decision
Provider requests pre-
service authorization
Clinical Consult
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Needed Information
If clinical information is needed, please be able to supply:
MemberMember ID
Member name
Date of birth (DOB)
Referring PhysicianPhysician nameNational provider identifier (NPI)Tax identification number (TIN)Fax number
Rendering FacilityFacility name
National provider identifier (NPI)
Tax identification
Supporting ClinicalPatient’s clinical presentation.Diagnosis Codes. Disease-Specific Clinical
• Prior tests, and/or prior imaging studies performed related to this diagnosis
• The notes from the patient’s last visit related to the diagnosis
• Type and duration of treatment performed to date for the diagnosis
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Pre-Service Authorization Outcomes
• Faxed to ordering provider and rendering facility
• Mailed to the member• Information can be printed on
demand from the eviCore healthcare Web Portal.
• Communication of denial determination
• Communication of the rationale for the denial
• How to request a Clinical Consult
• Faxed to the ordering provider and rendering facility
• Mailed to the member
Approved Requests• All requests are processed
within 2 days from receipt of request, not to exceed 14 calendar days. Please make certain all necessary clinical information has been submitted initially.
• Authorizations are typically good for 8 – 12 months from the date of determination.
Delivery Method
Denied Requests Delivery Method
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Pre-Service Authorization Outcomes
• eviCore will request a Physician-to-Physician review on any regimens that do not meet NCCN guidelines prior to issuing a determination. Denials may be issued if appropriate clinical justification is not available or an alternate regimen is not selected.
• Please note, once a request has been denied it cannot be overturned except upon appeal. A consult at this point would be advisory only.
Pre-Decision Consultation
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• Provides the ability to review clinical aspects of the case with a peer• Be prepared to provide information that was not submitted previously• Schedule the clinical consultations on line
Clinical Consultation
Select “Request a Consultation with a Clinical Peer Reviewer”
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Special Circumstances
Post Service Pre Claim Reviews• Post Service Requests must be submitted with 3 business days following the date of service. Requests
submitted after 3 business days will be administratively denied.• Post Service requests are reviewed for clinical urgency and medical necessity. Turn around time on a post
service review request is 30 calendar days.
Outpatient Urgent Procedures• Contact eviCore by web at www.eviCore.com or phone at 888-444-9261 to
request an expedited pre-service authorization review and provide clinical information.
• Urgent Cases will be reviewed with 24 hours of the request.
• eviCore will not process appeals.• Please contact healthplan to initiate an appeal request by calling the number on the back of the members
card.
Authorization Appeals
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Patients Already in Treatment
• Patients already in treatment prior to July 1, 2019 can continue the treatment plan until the end of the treatment course and will not require pre-service authorization from eviCore. The patient will need to be registered in the eviCore system, additional details on this process are in the FAQ.
• Any change request for treatment (i.e. new or additional drugs) must be submitted to eviCore.
Patients Already in Treatment:
Web Portal Services
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Portal Compatibility
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The eviCore.com website is compatible with the following web browsers:
• Google Chrome
• Mozilla Firefox
• Internet Explorer 9, 10, and 11
You may need to disable pop-up blockers to access the site. For information on how to disable pop-up blockers for any of these web browsers, please refer to our Disabling Pop-Up Blockers guide.
eviCore healthcare website
• Login or Register
• Point web browser to evicore.com
Creating An Account
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To create a new account, click Register.
Creating An Account
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Select CareCore National or MedSolutions as the Default Portal, and complete the user registration form.
Please note: For the MedSolutions portal, you will also need to select the appropriate Account Type: Facility, Physician, Billing Office, and Health Plan.
Creating An Account
30Review information provided, and click “Submit Registration.”
User Registration-Continued
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Accept the Terms and Conditions, and click “Submit.”
User Registration-Continued
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You will receive a message on the screen confirming your registration is successful. You will be sent an email to create your password.
Create a Password
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Uppercase letters
Lowercase letters
Numbers
Characters (e.g., ! ? *)
Your password must be at least (8) characters long and contain the following:
Account Log-In
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To log-in to your account, enter your User ID and Password. Agree to the HIPAA Disclosure, and click “Login.”
Account Overview
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Welcome Screen
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Providers will need to be added to your account prior to case submission. Click the “Manage Account” tab to add provider information.
Note: You can access the MedSolutions Portal at any time if you are registered. Click the MedSolutions Portal button on the top right corner to seamlessly toggle back and forth between the two portals without having to log-in multiple accounts.
Add Practitioners
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Click the “Add Provider” button.
Add Practitioners
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Enter the Provider’s NPI, State, and Zip Code to search for the provider record to add to your account. You are able to add multiple Providers to your account.
Adding Practitioners
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Select the matching record based upon your search criteria
Manage Your Account
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• Once you have selected a practitioner, your registration will be completed. You can then access the “Manage Your Account” tab to make any necessary updates or changes.
• You can also click “Add Another Practitioner” to add another provider to your account.
Case Initiation
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Initiating A Case
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Choose “request a clinical certification/procedure” to begin a new case request.
Select Program
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Select the Program for your certification.
Select Provider
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Select the Practitioner/Group for whom you want to build a case.
Select Health Plan
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Choose the appropriate Health Plan for the case request. If the health plan does not populate, please contact the plan at the number found on the member’s identification card.
Contact Information
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Enter the Provider’s name and appropriate information for the point of contact individual.
Member Information
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Enter the member information including the Patient ID number, date of birth, and patient’s last name. Click “Eligibility Lookup.”
Member History
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Example Patient 01/01/01Address GenderCity, State ZIP AgePhone Number
Plan ID Number
The Patient History Screen becomes the hub for all future requests or data relating to this patient. This includes a record of previous requests for services through eviCore, authorization numbers and dates, and clinical summaries based on the information provided through the request process.
Clinical Details
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Site Selection
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Select the specific site where the testing/treatment will be performed.
Clinical Certification
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• Verify all information entered and make any needed changes prior to moving into the clinical collection phase of the pre-services authorization process.
• You will not have the opportunity to make changes after that point.
Contact Information
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You can upload up to FIVE documents in .doc, .docx, or .pdf format. Your case will only be considered Urgent if there is a successful upload.
Select an Urgency Indicator and Upload your patient’s
relevant medical records that support your request.
If your request is urgent select No, if the case is standard
select Yes.
Clinical Pathway
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The Clinical Pathway begins with the selection of the cancer type. This will dictate the questions that will be asked in the following screens. All cancer types covered by NCCN
are available as well as an “Other” option for rare cancers not addressed by NCCN.
Clinical Pathway
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The user will be asked a series of questions necessary to generate the recommended treatment list for the patient being treated. A typical traversal will have between 5 and 12 questions based on the complexity of the cancer. The system will dynamically filter to only the minimum number of questions needed to complete the review.
Clinical Pathway
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All NCCN recommended treatments are displayed as well as an option to submit a custom treatment plan by selecting the individual drugs that will be administered.
All of the drugs in the selected regimen that require an authorization will be automatically included if approved.
Approval
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• Selection of a recommended regimen will result in immediate approval of all drugs in the requested regimen that require PA with an authorization time span sufficient to complete the entire treatment.
• No further action is needed unless the treatment needs to be changed due to disease progression or other clinical factors.
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Custom Treatment Plans
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Custom Treatment plans can be submitted for any case where the provider does not want to use a recommended regimen. Drugs are selected from a drop down list and the
user has the opportunity to attach or enter supporting information for the request.
Medical Review
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If additional information is required, you will have the option to either free hand text in the additional information box, or you can mark Yes to additional info and click submit
to bring you to the upload documentation page. Providing clinical information via the web is the quickest, most efficient method.
Medical Review
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If additional information is required, you will have the option to either free hand text in the additional information box, or you can mark Yes to additional info and click submit
to bring you to the upload documentation page. Providing clinical information via the web is the quickest, most efficient method.
Custom Treatment Plans
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• Custom plans are reviewed by an eviCore medical oncologist to determine if the request is clinically appropriate. Factors such as rare conditions, toxicity issues, or comorbidities may result in approval.
• If the request is not able to be approved, the eviCore Oncologist will request a physician-to-physician to discuss alternate treatment options that meet evidence based guidelines prior to issuing a denial. The goal is to eliminate the need for denials when acceptable alternatives are available.
• All reviews are completed within 48 hours of receiving complete clinical information.
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Building Additional Cases
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Once a case has been submitted for clinical certification, you can return to the Main Menu, resume an in-progress request, or start a new request. You can indicate if any
of the previous case information will be needed for the new request.
Authorization look up
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• Select Search by Authorization Number/NPI. Enter the provider’s NPI and authorization or case number. Select Search.
• You can also search for an authorization by Member Information, and enter the health plan, Provider NPI, patient’s ID number, and patient’s date of birth.
Authorization Status
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The authorization will then be accessible to review. To print authorization correspondence, select View Correspondence.
v
Eligibility Look Up
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You may also confirm the patient’s eligibility by selecting the Eligibility Lookup tab.
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Provider Resources
Client ProviderOperations
Pre-Certification Call Center
Web-Based Services
Documents
Provider Resources: Pre-Service Authorization Call Center
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7:00 AM - 7:00 PM (Local Time): 888-444-9261
• Obtain preauthorization or check the status of an existing case• Discuss questions regarding authorizations and case decisions• Change facility or CPT Code(s) on an existing case
Client ProviderOperations
Pre-Certification Call Center
Web-Based Services
Documents
Provider Resources: Web-Based Services
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www.evicore.com
To speak with a Web Specialist, call (800) 646-0418 (Option #2) or email [email protected].
• Request authorizations and check case status online – 24/7• Pause/Start feature to complete initiated cases• Upload electronic PDF/word clinical documents
Client ProviderOperations
Pre-Certification Call Center
Web-Based Services
Documents
Provider Resources: Client Provider Operations
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• Eligibility issues (member, rendering facility, and/or ordering physician)
• Questions regarding accuracy assessment, accreditation, and/or credentialing
• Issues experienced during case creation• Request for an authorization to be re-sent to the health plan
Client ProviderOperations
Pre-Certification Call Center
Web-Based Services
Documents
Provider Resources: Implementation Site
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Banner Healthcare Implementation site - includes all implementation documents:
https://www.evicore.com/healthplan/bannerhealth
• CPT code list of the procedures that require pre-service Authorization
• Quick Reference Guide• eviCore clinical guidelines• FAQ documents and announcement letters
To obtain a copy of this presentation, please contact the Client Services department at [email protected]
Provider Enrollment Questions Contact your Provider Network Consultant for more information
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Thank You!
