AMERIGROUP Ohio Provider Training Presentation


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

AMERIGROUP Ohio Provider Training Presentation

  1. 1. Provider Training Program 2010
  2. 2. Provider Training Program Agenda <ul><li>Welcome and Opening Remarks </li></ul><ul><li>AMERIGROUP Community Care Implementation of a Radiology Benefit Management (RBM) Program </li></ul><ul><li>About National Imaging Associates, Inc. </li></ul><ul><li>How the Program Works: </li></ul><ul><ul><li>Authorization Process </li></ul></ul><ul><ul><li>Authorization Appeals Process </li></ul></ul><ul><li>Provider Self-Service Tools (RadMD and IVR) </li></ul><ul><li>RadMD Demonstration </li></ul><ul><li>Provider Communication and Service as High Priorities </li></ul><ul><li>NIA Provider Relations and Contact Information </li></ul><ul><li>Questions and Answers </li></ul> Magellan Health Services, Inc. |
  3. 3. New Authorization Program for AMERIGROUP <ul><ul><li>Effective February 1, 2010 AMERIGROUP will implement a revised preauthorization/precertification program for outpatient imaging procedures. </li></ul></ul><ul><ul><li>The following procedures will require preauthorization/precertification through NIA. </li></ul></ul><ul><ul><ul><li>CT/CTA scan </li></ul></ul></ul><ul><ul><ul><li>PET scan </li></ul></ul></ul><ul><ul><ul><li>MRI/MRA </li></ul></ul></ul><ul><ul><ul><li>Nuclear cardiology </li></ul></ul></ul><ul><ul><li>AMERIGROUP will continue to manage claims adjudication and all medical policies and procedures. </li></ul></ul><ul><ul><li>New preauthorization /precertification policy affects services originating in outpatient settings only; emergency room, urgent care and inpatient imaging procedures do not require preauthorization /precertification. </li></ul></ul>NIA— A Magellan Health Company
  4. 4. About National Imaging Associates <ul><li>National Imaging Associates (NIA) - chosen by national and regional health plans, serving more than 18 million members, and offering: </li></ul><ul><ul><li>Distinctive clinical focus </li></ul></ul><ul><ul><li>National Committee for Quality Assurance accreditation and Utilization Review Accreditation Commission certification </li></ul></ul><ul><ul><li>Stability reinforced by parent company, Magellan Health Services </li></ul></ul><ul><ul><li>Enhanced operational competencies </li></ul></ul><ul><ul><li>Strong IT capabilities </li></ul></ul><ul><ul><li>Comprehensive patient support tools </li></ul></ul><ul><ul><li>Financial stability promoting growth and investment in innovative technology </li></ul></ul><ul><li>Focus and Results - Maximizing quality diagnostic services and promoting patient safety through: </li></ul><ul><ul><li>A clinically-driven process that safeguards appropriate diagnostic treatment for AMERIGROUP members </li></ul></ul><ul><ul><li>Convenient access to a network of qualified providers </li></ul></ul> Magellan Health Services, Inc. | NIA is accredited by NCQA and URAC
  5. 5. The NIA Provider Partnership Model <ul><li>Dedication to Provider Service and Convenience </li></ul><ul><ul><li>Dedicated provider relations staff </li></ul></ul><ul><ul><li>Authorization call center </li></ul></ul><ul><ul><li>Interactive Voice Response (IVR) tool </li></ul></ul><ul><ul><li>Innovative provider support tool – RadMD </li></ul></ul><ul><ul><li>Education and training programs </li></ul></ul><ul><ul><li>Ongoing outreach to providers – individual ordering/rendering, practice retraining, satisfaction surveys, etc. </li></ul></ul><ul><ul><li>Provider newsletters </li></ul></ul> Magellan Health Services, Inc. |
  6. 6. How the Program Works: The Authorization Process
  7. 7. Program Components <ul><li>Utilization Management/Authorizations: NIA's proprietary, evidence-based decision algorithms support scripting for call center representatives or online , leading to quick procedure approval or consultation with our radiology experts. </li></ul><ul><li>Information and Transaction Tools: Our online resource , , gives ordering providers the ability to request and obtain authorizations, reference lists of nearby imaging facilities, locate authorizations and submit 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. </li></ul>NIA— A Magellan Health Company
  8. 8. Clinical Validity of Algorithms <ul><li>NIA currently reviews more than 450,000 advanced imaging requests each month. </li></ul><ul><li>All algorithms and guidelines are reviewed and approved by AMERIGROUP Medical Directors. </li></ul><ul><li>Many of our current algorithms recommend the substitution of more costly but more effective imaging technology. Our goal is to suggest the most clinically appropriate test early in an episode of care. </li></ul><ul><li>Consultative communication is a hallmark of NIA – NIA has a team of 65 board-certified physicians representing radiology and a host of other specialties available for physician to physician discussions. </li></ul> Magellan Health Services, Inc. |
  9. 9. NIA Prior Authorization Process Magellan Health Services, Inc. | Physician’s office contacts NIA for prior consultation via web or telephone 100 percent of cases Procedure is approved by agent ~60 percent of cases Case is transferred to nurse for review ~40 percent of cases Procedure is approved by nurse ~20 percent of cases Case is transferred to physician for review ~20 percent of cases Procedure is approved by a physician reviewer ~10 percent of cases Procedure is denied by a physician reviewer ~5 percent of cases Case is withdrawn by the ordering physician ~5 percent of cases Agent Level Nurse Level ? ? Physician Level Call time of approximately 5 minutes On average, 92% of all cases receive final determinations within 24-48 hours. x    x
  10. 10. Authorization Process and Components (Annual Statistics) Magellan Health Services, Inc. | 173 Customer service associates 68 Staff in support roles 56 Initial clinical review staff (RN, LPNs, RT) 34 Staff in support roles 62 Board certified physician clinical reviewers Inbound calls 3,043,342 RadMD authorizations 1,015,432 St. Louis, MO Phoenix, AZ Case reviews 1,461,386 St. Louis, MO Phoenix, AZ Rancho Cordova, CA Case Reviews 547,629 San Diego, CA Phoenix, AZ West Palm Beach, FL Northbrook, IL Activity Staff Clinical ICR Clinical PCR Intake Call Locations
  11. 11. The Authorization Process
  12. 12. NIA Will Authorize: <ul><li>Nonemergent outpatient </li></ul><ul><ul><li>CT/CTA scan </li></ul></ul><ul><ul><li>MRA/MRI </li></ul></ul><ul><ul><li>PET scan </li></ul></ul><ul><ul><li>Nuclear cardiology </li></ul></ul><ul><li>Any code specifically cited in the AMERIGROUP/NIA Billable CPT ® Code Claims Resolution Matrix. </li></ul><ul><li>ALL other procedures will be adjudicated and paid by AMERIGROUP per their guidelines. </li></ul>Magellan Health Services, Inc. |
  13. 13. Claims Resolution Matrix 2009 (Draft) Matrix contains all CPT-4 codes NIA authorizes NIA— A Magellan Health Company THIS IS A SAMPLE LISTING ONLY A complete list will soon be available at If you require a paper copy, please contact Stephanie Martin, Provider Relations, NIA at 410-953-2631. Authorized CPT Code Description Allowable Billed Groupings 70336 MRI Temporomandibular Joint 70336 70450 CT Head/Brain 70450, 70460, 70470 70480 CT Orbit 70480, 70481, 70482 70486 CT Maxillofacial/Sinus 70486, 70487, 70488, 76380 70490 CT Soft Tissue Neck 70490, 70491, 70492 70496 CT Angiography, Head 70496 70498 CT Angiography, Neck 70498 70540 MRI Orbit, Face, Neck 70540, 70542, 70543
  14. 14. NIA Will Not Authorize: <ul><li>CPT codes that are not specifically cited in the AMERIGROUP/NIA Billable CPT Code Claims Resolution Matrix </li></ul><ul><ul><li>Inpatient CT/CTA scan, MRI/MRA, PET scan and nuclear cardiology </li></ul></ul><ul><ul><li>Emergency Room CT/CTA scan, MRI/MRA, PET scan and nuclear cardiology </li></ul></ul><ul><ul><li>Urgent Care CT/CTA scan, MRI/MRA, PET scan and nuclear cardiology </li></ul></ul>NIA— A Magellan Health Company
  15. 15. Urgent and Emergent Care CT-Guided Studies <ul><li>If an urgent clinical situation exists outside of a hospital emergency room, the radiologist or rendering provider should proceed with the study and contact NIA the next business day to proceed with the normal review process. </li></ul><ul><li>Separate precertification numbers are not needed for CT-guided biopsy or CT-guided radiation therapy. </li></ul>NIA— A Magellan Health Company
  16. 16. NIA’s Authorization Process <ul><li>The ordering physician is responsible for obtaining preauthorization/precertification. </li></ul><ul><li>The rendering provider must ensure that preauthorization/precertification has been obtained, and it is recommended that you not schedule procedures without prior authorization. </li></ul><ul><li>Procedures performed without proper authorization will not be reimbursed and may not be billed to AMERIGROUP members. </li></ul><ul><li>If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed the radiologist or rendering provider should proceed with the additional study and contact NIA within 1 business day to initiate the medical necessity review process. </li></ul><ul><li>If an urgent clinical situation exists outside of a hospital emergency room, the radiologist or rendering provider should proceed with the study and contact NIA the next business day to go through the normal review process. </li></ul><ul><li>Separate precertification numbers are not needed for CT-guided biopsy and CT-guided radiation therapy . </li></ul>NIA— A Magellan Health Company
  17. 17. Eligibility and Authorization Validity Period Guidelines <ul><li>If NIA has no eligibility information for the AMERIGROUP member for whom preauthorization/precertification is requested, NIA will attempt to verify member eligibility through a dedicated contact at AMERIGROUP. </li></ul><ul><li>If the selected imaging facility or a date of service within the originally approved authorization validity period needs to be changed, providers must contact NIA to change these components of the authorization. </li></ul><ul><li>If the exam needs to be changed or the authorization validity period needs to be extended beyond 60 days, contact NIA to withdraw the original exam request and complete a new authorization request. </li></ul>NIA— A Magellan Health Company
  18. 18. The Authorization Appeals Process
  19. 19. The Authorization Appeals Process <ul><li>In the event of a denial and you are not satisfied with a medical decision, you may appeal the decision through AMERIGROUP. NIA does not handle appeals. </li></ul><ul><li>You will receive a denial letter that contains appeal information. </li></ul>NIA— A Magellan Health Company
  20. 20. The Claims Process
  21. 21. How Claims Should be Submitted <ul><li>Rendering providers/imaging providers should continue to send their claims directly to AMERIGROUP. </li></ul><ul><li>Providers are strongly encouraged to use EDI claims submission with AMERIGROUP. </li></ul><ul><li>Providers can check claims status by logging on to the AMERIGROUP </li></ul><ul><li>web site at </li></ul>Magellan Health Services, Inc. |
  22. 22. The Claims Appeals Process
  23. 23. The Claims Appeals Process <ul><li>In the event of a prior authorization or claims payment denial, you may appeal the decision through AMERIGROUP. </li></ul><ul><li>Follow the instructions on your denial letter or explanation of payment notification. </li></ul> Magellan Health Services, Inc. |
  24. 24. Self Service Tools and Usage
  25. 25. Multi-Channel Provider Relations Strategy NIA— A Magellan Health Company Radiology Provider Interactive Voice Response High Touch <ul><li>Internet Offerings </li></ul><ul><li>Initiate authorization (ordering provider) </li></ul><ul><li>Authorization Inquiry </li></ul><ul><li>Provider Relations Staff </li></ul><ul><li>Provider support and inquiries </li></ul><ul><li>Provider education/forums </li></ul><ul><li>Centralized and regional support </li></ul><ul><li>IVR – Interactive Voice Response </li></ul><ul><li>Authorization Inquiry </li></ul>
  26. 26. RadMD Demonstration
  27. 27. Self Service Tools and Uses <ul><li>Interactive Voice Response (IVR) </li></ul><ul><ul><li>Use tracking number to check case status </li></ul></ul><ul><li>Web site: </li></ul><ul><ul><li>Use tracking number to review an exam request </li></ul></ul>NIA— A Magellan Health Company
  28. 28. NIA Website <ul><li>The NIA web site gives providers access to: </li></ul><ul><li>Information concerning approved authorizations. Go to and login with username and password . </li></ul><ul><li>Search the site using the patient’s ID number, name or authorization number. </li></ul>NIA— A Magellan Health Company
  29. 29. NIA Web Site – Ordering Providers <ul><li>The NIA web site supports ordering providers with: </li></ul><ul><li>Instant, easy access to high tech imaging prior authorization information </li></ul><ul><li>Online authorization of most cases; pended cases will be resolved through our Clinical Review Department </li></ul><ul><li>Up to the hour information on member authorizations, including date initiated, date approved, exam category, valid billing codes and much more </li></ul><ul><li>We encourage ordering providers to submit all requests on line. </li></ul>NIA— A Magellan Health Company
  30. 30. NIA Web Site - Imaging Facilities <ul><li>The NIA web site supports imaging facilities with: </li></ul><ul><li>User friendly, near-real-time Internet tool </li></ul><ul><ul><li>Available Monday – Friday, 5:00 a.m. to 12:00 a.m. Eastern Time; </li></ul></ul><ul><ul><li>Saturday 8:00 a.m. to 1:00 p.m. Eastern Time </li></ul></ul><ul><ul><li>Log on to RadMD for direct access to members’ authorization information, including: </li></ul></ul><ul><ul><ul><li>Date initiated </li></ul></ul></ul><ul><ul><ul><li>Exam requested </li></ul></ul></ul><ul><ul><ul><li>Valid billing codes (CPT) </li></ul></ul></ul><ul><ul><ul><li>Current provider news </li></ul></ul></ul><ul><li>Access to a full range of helpful content, Diagnostic Imaging Guidelines and Quick Reference Guide </li></ul>NIA— A Magellan Health Company
  31. 31. <ul><li>Login and click the new user button on the right side of the home page. </li></ul><ul><li>Fill out the application and click the submit button. </li></ul><ul><li>You must include your e-mail address in order for our webmaster to respond to you with your NIA-approved username and password. </li></ul><ul><li>HIPAA regulations require everyone in your organization to have his or her own username and password. </li></ul><ul><li>On subsequent visits to the site, click the login button to proceed. </li></ul>To get started, visit Magellan Health Services, Inc. |
  32. 32. RadMD User Survey Findings <ul><li>Q: What are the three most notable characteristics of this tool? </li></ul><ul><li>Common Themes: </li></ul><ul><ul><li>“ Enjoy using RadMD because it saves time and is user-friendly.” </li></ul></ul><ul><ul><li>“ To the point, no long detailed explanations” or “repeat questions.” </li></ul></ul><ul><ul><li>“ Provides immediate status of authorizations.” </li></ul></ul><ul><ul><li>“ Don’t have to tie up phone lines.” </li></ul></ul><ul><li>Other Responses: </li></ul><ul><ul><li>“ You can work at your own pace.” </li></ul></ul><ul><ul><li>“ Questions are easier to answer because you see them.” </li></ul></ul>NIA— A Magellan Health Company
  33. 33. RadMD User Survey Findings <ul><li>Q: What advice relative to using RadMD would you give to physicians’ offices that don’t yet use RadMD? </li></ul><ul><li>Common Themes: </li></ul><ul><ul><li>“ Simply try it as a time saver.” </li></ul></ul><ul><ul><li>“ Great service - never any problems.” </li></ul></ul><ul><ul><li>“ Would save the office so much time from calling and being on the phone. Was easy from the onset to use.” </li></ul></ul><ul><li>Other Responses: </li></ul><ul><ul><li>“ Tell them to try it at least once. I was hesitant at first but found it to be very straightforward. Also has noticed that we have tweaked our guidelines for more approvals on-line for brain MRI over the 3 years using RadMD.” </li></ul></ul><ul><ul><li>“ Convenient and fast- can start a request, if called away. can pick it back up, where if you are on the phone you have to hang up then call back later.” </li></ul></ul>NIA— A Magellan Health Company
  34. 34. NIA Provider Relations
  35. 35. Provider Relations Structure and Portals <ul><li>Stephanie Martin, dedicated NIA Provider Relations Manager for AMERIGROUP providers will: </li></ul><ul><ul><li>Educate ordering and rendering providers as to how the program works. </li></ul></ul><ul><ul><li>Serve as a liaison for AMERIGROUP Provider Relations and NIA. </li></ul></ul><ul><ul><li>Answer your questions and help you with researching issues </li></ul></ul><ul><ul><li>Contact information: </li></ul></ul><ul><ul><ul><ul><li>Phone 410-953-2631 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>E-mail at [email_address] </li></ul></ul></ul></ul> Magellan Health Services, Inc. |
  36. 36. Questions and Answers