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ev1Core • healthcare innovative solutions •

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Prior Authorization of Chiropractic Services and Physical Medicine

Therapy corePath® Migration

Beginning: March 1st, 2018

© 2018 ev iCore healthcare. All Rights Reserv ed. This presentation contains CONFIDENTIAL and PROPRIETARY inf ormation.

... What is Therapy corePath® ?

We’ve received your feedback and modified our approach

Appropriate

Decision

Focused on the member

Authorization strategy

emphasizes the unique attributes

of a specific member’s condition and any associated complexities.

Streamlined for providers

Providers will experience a

simplified and consistent prior

authorization process that

requires only key clinical

information.

Condition-specific approvals

Visits allocated in accordance with

condition severity/complexity,

functional loss and confirmation that care

is progressing as planned.

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....... • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Pathway Comparisons: Standard Processing

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7 day time frame to request services

Authorizations will still reflect the following:

Visits/Units

Specific authorization timeframes

Date Extension / Backdate Request Process

Login Credentials for the eviCore Portal

Authorization for developmental pediatric conditions

Authorization for speech therapy

The following processes will remain the same

... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. .

Pathway Comparisons: Initial requests

We’ve received your feedback and modified our approach

Out with the OLD…

in with the NEW…

• Function-based – incorporates

clinical, social, ADL factors

• Validated assessments – objective comparison

• Clinical factors that identify more

complex cases based on key

clinical, chronicity

• Patient severity and complexity

established at entry point

• Exam-focused questions with

optional functional assessment

• Variability of clinical assessment

due to skill, practice patterns, etc.

• Complexity not addressed

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... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pathway Comparisons: Follow-up requests

We’ve received your feedback and modified our approach

• Re-statement of functional status

• Focus on progress and

effectiveness of treatment – ‘dynamic assessment’

• Identify progress – attestation

plus functional scale change

• Identify reasons for lack of

progress – compliance, re-injury,

exacerbation, etc.

Out with the OLD…

In with the NEW…

• Repeat questions requiring

review and comparison to

previous clinical picture

• No indication of progress

• Focus on static clinical factors,

assessment of treatment

effectiveness inferred

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This reciuest iS for treatment of:

@ New co:nllilbn lhat has mot had pre ,ous lrealment

0 An e>:iisting conllitian lhal has had previous lrealment

O llnlmown

Is there a second area be ng treated? If so. please l d1cate belo 01.

o second area being treated ~

Date :

Your u st d a treatm nt tart d te of 06/13/2017

Sample Physical Medicine corePath® Pathway

Initial Requests Case related questions:

• Identify new care vs. continuing

care based on treatment area, not

time

1

2

3

• Identify primary area of treatment

• First indicator of complexity – second unrelated treatment area

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Please enter_ !Index score (in%) 146,

Does you paUe _ ave 1radla_·ng p_ · belo _ e mee?

® Yes O ,o O Un'lmO\'m

How man occunences of lo I back pain has your pa ·ent had in lhe past 3 y,ears ~

0 1 @2, 0 3 0 4ormore

iJ1Muil

Sample Physical Medicine corePath® Pathway

Initial Requests, continued….

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5

6

Initial clinical questions:

• Enter functional score, if available

• Oswestry Index

• Neck Disability Index

• LEFS

• Dash / QuickDASH

• HOOS JR/KOOS JR

• Incorporates ROM, Strength, Pain, etc.

• Complexity:

• Neural signs

• Chronicity

High potential for immediate approval whenpathway is completed. 7

Please enter the Os vestry Disability Index score (in %)

141

Please enter the previous ODI score

146

Does your patient have radiating pain below the knee?

0 Yes ®No

Has your patient progressed as expected?

@Yes 0 No

111·,lnil

Sample Physical Medicine corePath® Pathway

Follow-up request Follow-up clinical questions:

1

2

3

• Current and previous functional

score

• Complexity question – neural

signs

• Progress

o Validated scores have MCD

(minimal clinical difference) as

progress indicator

o Clinical assessment

High potential for immediate approval whenpathway is completed. 8

Yol!J indicated fllat your patient is NOT progressing as expected. Please indicate if any of the following oc.curre(I:

~ Paitie:nt "overdid" acUviities or exercise resu lting in teinporaiy increase in symptoms D New injury resulting ilfl significant cha11ge

D Symptoms prngresse(I despite trea1!ment D Patient did not participate in dinical visits or !110me prngrain

lease i11dicate, the nab.Ire of the new injury OR ove:ruse incident. N/ A

V

Sample Physical Medicine corePath® Pathway

Follow-up request – Lack of progress identified

Lack of progress:

• Categories of explanations

• Used in algorithm to determine care

• Future, additional pathway to identify details

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Prior authorization requests

How to request prior authorization:

WEB

www.eviCore.com

Available 24/7 and the most

efficient way to create prior

authorizations and check existing

case status.

Web submissions also have a high potential for immediate approval!

Or by:

Phone: (855) 252-1115

7 a.m. to 7 p.m.

(Local Time)

Monday through Friday

Fax: 855.774.1319

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Program: PT/OT Therapy Intake Form .· .... ovicore ; healthcare

Required for all MSK Conditions (Including Hand) PJease use this fax fOfTil for NON-URGENT requests only. Failure to provide all relevant information may delay the detemiination. Phone and fax numbers may be found on eviCore.com under the Guideines and FOflllS section. You may also log into the provider portal located on the site to sl.bnit an authorization request.

.. .. URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE

Previo us Reference/Auth Humber (If Continued Care ): Date of Subm ission:

Service T ype Requesled: D Physical Therapy D Occupational Therapy

First Name: I ( Ml: I I Last Name: I ... Member lD: I DOB (mm/dd/yyyy): ! Gender: D Male D Female z

Street Address: ~ l Apt # : I w ;:: City: ( Stale: f l Zip: <( n. Home Phone: I I CeU Phone: ! Primary: D Home D Cell

Member Health Plan/Insurer:

First Name: I ~ Last Name: I 0:: Primary Specialty: ~ I TIN: I I NPI: ' w C Physician Phone: ~ I Physician Fax: I 5

Address: j I Suite•: 0 0:: City: I ( Stale: I I z; p: I n.

Office Contact ~ I Ed : I ~ Email: f

Diagnoses:

I Code

I Description

I I Code

I Descn'"ption

I Start Date for this Request :

This is a (se lect the most appropriate): I D New condition not previously treated D Same/previous condition

Date of initial evaluation: ~ I Date of onset of condition : I 4 Date of current findings: I Primary Treatment Area:

Spine: D Cervical I Upper Thoracic D Lower Thoracic I Lumbar I Pelvis

w Upper EKtremity: D Shoulder I Arm D Elbow / Wrist / Forearm D Hand > Lower Extremity: D Hip/Thigh D Knee D An kle I Foot

!:i other. D Pelvic Pain/ Incontinence 0:: ... (/) Secondarv Treatmen t Area: z Spine: D Cervical / Upper Thoracic D Lower Thoracic/ Lumbar/ Pelvis ~

Upper Extremity: I D Shoulder / Arm D Elbow/ Wrist / Foreann D Hand C <( Lower Extremity: D Hip / Thigh D Knee D Ankle / Foot

Other: I D Pelvic Pain / Incontinence

Previous Treatment - Leave Blank if NJA:

If the member requ ires treatment for a new condition, what was the previous condition? D N/A

D Cervical / Upper Thoracic D Lower Thoracic / lumbar I Pelvis D UE - Shoulder/Arm D UE- Hand

D UE - ElbowM'ristlforearm D LE - Hip/Thigh D LE - Knee D LE - Ankle/Foot

D Pelvic Pain/ lnc.ontinence

What is the status of the previous treatment? D Condition Resolved D Ongoing Treatment D N/A

Is this request for fabricating a splinUorthotic or developing a home exercise program only? D Yes D No

Sample Physical Medicine corePath® Forms

Worksheets for corePath® are available for:

Physical Therapy

Occupational Therapy

Chiropractic Services

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~ . . . . . . . . . . . . . .

Therapy corePath® Summary

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Elimination of pre-set waivers

Increased provider satisfaction

Reduced administrative burden for providers

Increased opportunity for real-time decisions

Expanded, member-focused decisions

Decreased case review turn-around-times

Patients able to receive the right amount of care in a timely manner

Important Links:

Intake Forms PT/OT MSK (includes Hand & Pelvic Health)

PT/OT Vestibular

PT/OT Lymphedema

Chiropractic Services

Continue to use the legacy forms for:

PT/OT Adult Neurologic

For additional Clinical Worksheets / Intake Forms, Please visit

https://www.evicore.com/resources/Pages/providers.aspx

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ev1Core • healthcare innovative solutions •

• • •• •

Thank You!

https://www.evicore.com/resources/Pages/providers.aspx

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