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© 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.
Musculoskeletal Prior Authorization for Highmark
Provider Orientation
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Company Overview
2
Radiology
Cardiology
Musculoskeletal
Sleep Management
Medical Oncology
Specialty Drug
Radiation Therapy
Lab Management
Post-Acute Care
9 Comprehensive
Solutions
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
3
Comprehensive
Solutions 9 The industry’s most
comprehensive clinical
evidence-based guidelines
4k+ employees including
1k clinicians
Engaging with 570k+ providers
100M Members
Managed
Nationwide
4
Headquartered in Bluffton, SC and offices across the US
including:
• Melbourne, FL
• Plainville, CT
• Sacramento, CA
• Lexington, MA
• Colorado Springs, CO
• Franklin, TN
• Greenwich, CT
Musculoskeletal Management Solution - Our Experience
30+ Regional and National Clients
Members Managed
• 25.5M Commercial Memberships
• 2M Medicare Memberships
• 6.5M Medicaid Memberships
300k+
Cases built per day
40M members managed nationwide
5
10 Years Managing Radiation Therapy Services
6
Clinical Staffing
44 Musculoskeletal
physicians on staff
66
Musculoskeletal-trained
nurses on staff
40 Million lives
covered
56 Musculoskeletal
therapists (PT/OT/ST/MT/CHIRO/ACU)
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Our Clinical Approach
7
Multi-Specialty Expertise
• 190+ board-certified medical
directors
• Diverse representation of medical
specialties
• 450 nurses with diverse
specialties and experience
• Dedicated nursing and physician
teams by specialty for
Cardiology, Oncology, OB-GYN,
Spine/Orthopedics, Neurology,
and Medical/Surgical
8
Clinical Platform
Family Medicine
Internal Medicine
Pediatrics
Sports Medicine
OB/GYN
Cardiology
Nuclear Medicine
Anesthesiology
Radiation Oncology
Sleep Medicine
Oncology/Hematology
Musculoskeletal
• Orthopedic
Surgery
• Spine Surgery
• Interventional
Pain
Radiology
• Nuclear Medicine
• Musculoskeletal
• Neuroradiology
• American Academy of Neurology
• American College of Rheumatology
• American Association of Neurological Surgeons
• American Academy of Orthopedic Surgeons
• American Society of Interventional Pain Physicians
• North American Spine Society
• American College of Occupational and
Environmental Medicine
• American Academy of Physical Medicine and
Rehabilitation
• American Association of Hip and Knee Surgeons
• American Pain Society
• Official Disability Guidelines
• Medicare Guidelines
• Spine Intervention Society
• American Academy of Orthopedic Surgeons
• The American Orthopedic Society for Sports Medicine
• Cochrane Reviews
• American Physical Therapy Association
• American Chiropractic Association
• American Occupational Therapy Association
• American Speech Language Hearing Association
• American Society of Anesthesiologists
Evidence-Based Guidelines
9
The foundation of our musculoskeletal solution:
Aligned with National Societies
Dedicated
pediatric
guidelines
Medicare
LCDs & NCDs
Academic
institutional
experts and
community
physician panels
Current
clinical
literature
The Client Provider Operations team is responsible for high-level service delivery to
our health plan clients as well as ordering and rendering providers nationwide
Client Provider Operations
10
Best Colors
Client Provider
Representatives
are cross-trained to
investigate escalated
provider and health
plan issues.
Client Provider
Representatives
Client Experience
Managers lead
resolution of complex
service issues and
coordinate with partners
for continuous
improvement.
Client Experience
Managers
Regional Provider Engagement
Managers are on-the-ground
resources who serve as the voice of
eviCore to the provider community.
Regional Provider
Engagement Managers
Why Our Service Delivery Model Works
11
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.
12
Musculoskeletal
Prior Authorization Program
for Highmark
eviCore will begin accepting requests on September 24, 2018 for dates of service October 1,
2018 and beyond
Program Overview
13
Prior authorization applies
to services that are:
• Outpatient
• Inpatient
• Elective / Non-emergent
Prior authorization
does not apply* to services
that are performed in:
• Emergency room
• Observation stay
It is the responsibility of the rendering provider to verify that the
necessary authorization has been obtained before providing the service.
*An urgent unplanned inpatient hospital stay must be authorized
through Highmark, with the hospital providing notification and clinical
information for the inpatient request within 48 hours of the urgent
unplanned admission.
Applicable Membership
14
Prior authorization by eviCore is required for Highmark members in
Pennsylvania, Delaware and West Virginia enrolled in the following programs:
• Commercial Fully Insured
• Medicare Advantage
• Affordable Care Act
Highmark will manage prior authorizations for MSK surgeries or IPM
services for all other members according to the member's benefits.
Benefits can vary by member contract, so please be sure to check the
member's benefits before delivering care to confirm if an
authorization is required. NaviNet® is available to help you check
member benefits and to verify if an authorization is required.
15
Prior Authorization Required:
To find a list of CPT
(Current Procedural Terminology)
codes that require prior authorization
through eviCore, please visit:
https://www.evicore.com/healthplan/highmark
Joint Surgery
• Large joint replacement (Includes Hip, Knee, and Shoulder
• Arthroscopic and open procedures (Includes Hip, Knee, and
Shoulder)
Spine Surgery
• Spinal Implants
• Electrical bone growth stimulators
• Pain Pumps (Implantable intrathecal drug delivery
system)
• Graft (Implant – Allograft/Autograft)
• Cervical/Thoracic/Lumbar
• Decompressions
• Fusions
• Total Disc Arthroplasty (Cervical/Lumbar)
• Vertebroplasty/Kyphoplasty
• Microdiscectomy (Cervical/Lumbar)
Interventional Pain
• Spinal injections (Includes Sacroiliac Joint, Epidural steroid
injections, Facet Joint injections, Regional Sympathetic
Blocks)
• Chemodenervation – Botulinum Toxin Injections
• Radiofrequency Joint Ablation Denervation
• Spinal implants
• Spinal cord stimulators
• Pain pumps (Implantable intrathecal drug delivery
system)
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
How to request prior authorization:
Prior Authorization Requests
16
Or by phone*:
888-564-5492
7:00 a.m. to 7:00 p.m.
EST
Monday - Friday
WEB
NaviNet®
Available 24/7 and the quickest
way to create prior authorizations
and check existing case status
Fax* option: 800.540.2406 Fax forms available at www.evicore.com
*For members managed by Highmark, NaviNet remains the preferred method. If phone or fax submission is needed the Highmark phone
and fax numbers should be used.
Clinical Review Process
17
Easy for
providers
and staff
START
Methods of Intake
Nurse
Review
Predictive
Intelligence/Clinical
Decision Support
Appropriate
Decision
MD
Review
Clinical
Consultation
Real-Time Decision with Web and Phone
Needed Information
18
Member Member ID
Member name
Date of birth (DOB)
Facility Facility name
National provider identifier (NPI)
Tax identification number (TIN)
Street address
Rendering/Ordering Physician
Physician name
National provider identifier (NPI)
Tax identification number (TIN)
Fax number
i Requests
CPT code(s) for
requested procedure
The appropriate
diagnosis code for the
working of differential
diagnosis
If clinical information is needed, please be able to supply:
• Imaging studies and prior test results related to the diagnosis
• Office notes related to the current diagnosis
Prior Authorization Outcomes
19
• All requests are processed within 2 business days
after receipt of all necessary clinical information.
• Authorizations are typically good for 60 calendar
days from the date of determination.
• Highmark will honor existing prior authorizations for
continuity of care on claims for MSK surgeries or
IPM services that overlap during the transition to the
new program.
Approved Requests:
• Faxed to ordering provider
• Mailed to the member
• Information can be printed on demand from the
Highmark provider web portal
Delivery:
• Communication of denial determination
• Communication of the rationale for the denial
• How to request a Peer Review for commercial
members
• Faxed to the ordering provider
• Mailed to the member
• Information can be printed on demand from the
Highmark provider web portal
Delivery:
Denied Requests:
Delivery:
Prior Authorization Outcomes – Commercial
20
• Additional clinical information can be provided
without the need for a physician to participate
• Must be requested on or before the anticipated date
of service
• Commercial members only
Reconsiderations
Peer-to-Peer Review
• If a request is denied and requires further clinical
discussion for approval, we welcome requests for
clinical determination discussions from referring
physicians. In certain instances, additional
information provided during the consultation is
sufficient to satisfy the medical necessity criteria for
approval.
• Peer-to-Peer reviews can be scheduled at a time
convenient to your physician
• Commercial members only
Peer-to-Peer Review:
Prior Authorization Outcomes – Medicare / Medicare Advantage
21
• If your case requires further clinical discussion for approval, we welcome
requests for clinical determination discussions from referring physicians
prior to a decision being rendered.
• In certain instances, additional information provided during the pre-
decision consultation is sufficient to satisfy the medical necessity criteria
for approval
Pre-Decision Consultation
Special Circumstances
22
Retrospective Reviews:
• Retro requests must be submitted within 730
business days following the date of service.
Requests submitted after 730 business days will be
administratively denied.
• Retro requests can be submitted via phone or fax.
• Retro requests are reviewed for medical necessity.
Turnaround time on retro requests is 30 calendar
days.
• Retro requests for dates of service before
10/1/2018 must be submitted to Highmark
Urgent Outpatient Studies:
• Contact eviCore by phone to request an expedited
outpatient prior authorization review and provide
clinical information
• Urgent Outpatient Cases will be reviewed within 24
hours not to exceed 72 hours of the request.
• eviCore will process first level provider appeals for
Commercial members.
• Requests for appeals must be submitted to
eviCore within 365 calendar days of the initial
determination
• The procedure request and all clinical information
provided will be reviewed by a physician other
than the one who made the initial determination.
• A written notice of the appeal decision will be
mailed to the member and faxed to the provider
• Highmark will process first level provider appeals
for Medicare Advantage members.
• Appeals for services that were denied before
10/1/2018 must be submitted to Highmark
Medical Necessity Appeals:
Special Circumstances
23
• Spine surgery and joint surgery prior
authorizations can be extended for 60 days.
Please contact eviCore by phone to request a
date extension.
• Interventional Pain prior authorizations are not
eligible for date extensions.
Date Extensions:
Interventional Pain Management: Epidural Steroid Injections
24
• There is insufficient scientific evidence to support
the scheduling of a “series-of-three” injection in
either a diagnostic or therapeutic approach.*
• The medical necessity of subsequent injections
should be evaluated individually and be based on
the response of the individual to the previous
injection with regard to clinically relevant
sustained reductions in pain, decreased need for
medication and improvement in the individual’s
functional abilities*
Series-of-three:
* Please refer to eviCore’s evidence based guidelines www.evicore.com
Spinal Surgery: Smoking Cessation
25
• Highmark has made the decision not to enforce
at this time smoking cessation as a requirement
in the spinal surgery medical necessity criteria.
Highmark promotes evidence-based health care
and shared decision-making to inform patients
and practitioners on how to achieve the best
health outcomes.
Smoking cessation:
* Please refer to eviCore’s evidence based guidelines www.evicore.com
26
Web Portal Services
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Single-Sign On for Highmark Providers
27
A category for Musculoskeletal / lnterventional Pain Management
has been added to the Eligibility and Benefits screen in NaviNet
to indicate if authorization is required.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Single-Sign On for Highmark Providers
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Single-Sign On for Highmark Providers
Inpatient - Providers must select either Large Joint
Procedures or Spine Surgery Procedures under the
Service selection
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Single-Sign On for Highmark Providers
Outpatient - Providers must select either Pain
Management Procedures, Large Joint Procedures or
Spine Surgery Procedures under the Service selection
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Single-Sign On for Highmark Providers
The Referred To Facility must be provided for inpatient authorizations. If the
Referred to Facility is not provided, the claim may be denied.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Single-Sign On for Highmark Providers
The Referred To Facility must be provided for inpatient authorizations. If the
Referred to Facility is not provided, the claim may be denied.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Contact Information
33
Confirm the Provider’s name and appropriate
information for the point of contact individual.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Member History
34
This is the Member History screen. If the patient has a history of requests from the
provider it will populate on this screen.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Verify Service Selection
35
ICD-10 Code
ICD-10 Code
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Clinical Certification
36
• Verify all information entered and make any needed changes prior to moving
into the clinical collection phase of the prior authorization process.
• You will not have the opportunity to make changes after that point.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Pause/Save Option
37
Once you have entered the clinical collection phase of the case process, you can save
the information and return within (2) business days to complete.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Medical Review
38
Acknowledge the Clinical Certification statements, and hit “Submit Case.”
Approval
39
Once the clinical pathway
questions are completed
and the answers have met
the clinical criteria, an
approval will be issued.
Print the screen and store
in the patient’s file.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Medical Review
40
If additional information is required, you will have the option to either upload
documentation, enter information into the text field, or contact us via phone.
Authorization look up
41
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.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Authorization Status
42
The authorization will then be accessible to review. To print authorization
correspondence, select View Correspondence.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Provider Resources
43
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Musculoskeletal Online Resources
44
Clinical Guidelines, FAQ’s, Online Forms, and other important resources can be
accessed at www.evicore.com. Click “Solutions” from the menu bar, and select the
specific program needed.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Musculoskeletal Online Resources
45
Clinical Worksheets and Fax Forms can be accessed at www.evicore.com. Click
“Resources” & “Providers” from the menu bar. Click “Online Forms &
Resources”& Select Solution “Musculoskeletal” from the dropdown menu.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
eviCore Provider Blog Series
46
• The eviCore blog series focuses on making processes more efficient and easier
to understand by providing helpful tips on how to navigate prior authorizations,
avoid peer-to-peer phone calls, and utilize our clinical guidelines.
• You can access the blog publications from the Insights tab or via the direct link
at https://www.evicore.com/pages/media.aspx.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Client Provider
Operations
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Prior Authorization Call Center
47
7:00 AM - 7:00 PM (EST): (888) 564-5492*
• Obtain pre-certification 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
• To request a Clinical Consultation
• Status checks
eviCore fax* number: (800) 540-2406
*For members managed by Highmark, NaviNet remains the preferred method. If phone or fax submission is needed
the Highmark phone and fax numbers should be used.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Client Provider
Operations
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Web-Based Services
48
www.evicore.com
To speak with a Web Specialist*, call (800) 646-0418 (Option #2) or
email portal.support@evicore.com.
• Pause/Start feature to complete initiated cases
• Upload electronic PDF/word clinical documents
*For issues with NaviNet, click on Help at the top of Highmark Plan Central to access NaviNet Support
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Client Provider
Operations
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Client Provider Operations
49
clientservices@evicore.com
• Issues experienced while building a prior authorization request
• Reports of eviCore system issues
8:00 AM – 8:00 PM (EST): (800) 575-4517
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Client Provider
Operations
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Implementation Document
50
Higmark Implementation site - includes all implementation
documents:
https://www.evicore.com/healthplan/highmark
• Provider Orientation Presentation
• CPT code list of the procedures that require prior authorization
• Quick Reference Guide
• eviCore clinical guidelines
• FAQ documents and announcement letters
Materials are also available on the Highmark Provider Resource
Center Site under Care Management Programs
You can obtain a copy of this presentation on the implementation site listed
above. If you are unable to locate a copy of the presentation, please contact
the Client Provider Operations team at ClientServices@evicore.com.
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Thank You!
51
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