avera health plans health plans is now partnered with carecore national to provide quality support...
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P R O V I D E R O V E R V I E W
Avera Health PlansIn Partnership with CareCore National
Advanced Outpatient Imaging Changes for July 1, 2012
Avera Health Plans is now partnered with CareCore National to provide quality support in managing prior authorization for
outpatient radiology services, effective July 1, 2012 for services rendered on or after July 1, 2012.
CareCore National is a nationally recognized, physician founded Healthcare Solutions services corporation.
CareCore is URAC accredited, NCQA certified and Cybertrust Secured.
CareCore has the industry’s most extensive and current set of evidence-based specialty criteria.
Through CareCore’s established reputation for quality leadership and excellent customer service, they are the largest and fastest growing benefits management firm in the U.S.
Who is CareCore National?
Impacts members enrolled in:
• Avera Health Plans fully insured
• Avera MyPlan individual health insurance
• Avera employee health insurance plans
When reviewing the Avera Health Plans member ID card,
look at their Group Number.
Group Numbers Starting With:
•SD, IA and NE = Fully Insured
•IND or SING = Avera MyPlan
•AAH = Avera Employees
Members that Require Prior Authorization
The ordering physician/designee* is responsible for obtaining the authorization via:
Phone: 1 (866) 668-8295
- or -
Online:: www.CareCoreNational.com
CareCore National Call Center Hours:7 a.m. to 7 p.m. CT, Monday through Friday.
Website is available 24/7.
* A designee may be a member of the ordering physician’s office staff.
Prior Authorization Responsibility
•CT/CTA•MRI/MRA•PET Scan•Nuclear Cardiology•Nuclear Medicine
A full listing of imaging procedures and codes that will require prior authorization can be found on our website, www.AveraHealthPlans.com on the provider login page.
Avera Health Plans’ Advanced Outpatient Imaging Prior Authorizations Will Include:
Modalities Requiring Prior Authorization
Prior authorizations are required in all places of service except when the procedure is rendered:
• In an Emergency Room (place of service = 23) • In an Inpatient Hospital setting (place of service = 21).
Place of Service and Prior Authorizations
Physician evaluates clinical problem and determines an advanced imaging study is warranted that requires a prior authorization.
Physician seeks prior authorization request:
- Online
- Phone
Clinical Review Nurse will assess complete clinical information against Evidence Based Specialty Criteria.
Physician reviews case and a determination based on medical necessity is made.
Approval or case is sent for further review by
Medical Director.
Clinical personnel will review history and findings against evidence based criteria.
Prior Authorization Process
Case Numbers• A case number is assigned to EVERY request. • Case numbers are used for reference purposes only and
are not valid for claim payment. • The format is a 10-digit numeric value.
• Example: 1004567890
Authorization/Determination Numbers• A determination number is assigned to every case upon
completion of the review.• Authorization numbers are used systematically to validate
claim payment.• The format is an alpha code followed by numeric values and
the CPT code. • Example : A012345678-70450
Prior Authorization Details
Authorizations are valid 45 calendar days from the date of approval.
An approval date is the date the case is approved.
Most authorizations will be immediate (by phone or online).
NOTE: If further review is needed, CareCore has two business days to make medical necessity determination.
Prior Authorization Details
At any point in the case management process, the ordering physician may request to speak to a CareCore National Medical Director.
Call: 1 (866) 668-8295
Follow prompts.
Prior Authorization Details
• Cases not consistent with evidence-based criteria may not be certified.
• Both the provider and the patient will be notified by letter of cases not certified.
• Letters of noncertification will include the guidelines for the appeals process.
For questions or concerns around appeals, contact Avera Health Plans Service Center at (605) 322-4545 or toll-free at 1 (888) 322-2115.
Noncertification Determination
Noncertification Determination
Reconsiderations
Ordering physicians may request a reconsideration within 14 business days of determination by calling CareCore at 1 (866) 668-8295.
Please include additional clinical information that may need to be considered.
Noncertification Determination
AppealsAn ordering physician or member can initiate an appeal by contacting Avera Health Plans:
Email: [email protected]
Mail:Complaint and Appeals CoordinatorAvera Health Plans3816 S. Elmwood Ave, Suite 100Sioux Falls, SD 57106
Fax: 1 (800) 269-8561
More detailed instructions are included in the determination letter.
If the CPT® code for the authorized procedure differs from the code for the rendered procedure, the ordering or rendering provider is required to contact CareCore National at 1 (866) 668-8295 and select Customer Service to modify the request.
Please note that clinical documentation to support the change will be required.
• Change in modality• Adding contrast agents• Addition of contiguous body parts
You have up to two business days from the date of service to request a modification.
Updating Existing Authorization
Urgent requests must be made by phone only.
Urgent Prior Authorization Requests
To initiate an urgent prior authorization request, please call CareCore at 1 (866) 668-8295* and follow the prompts. You must state that the request is clinically urgent.
*Same as prior authorization phone number
• Clinically urgent cases will be reviewed and a determination will be made within three hours after CareCore National receives the required clinical information.
• Urgent requests may be initiated by the ordering physician and/or the designee.
CareCore National Web Portal Access
Referring Physicians•Initiate Authorizations•View Authorization status•Access reference material•Information and tutorials
Rendering Providers•Eligibility lookup•View Authorization status•Access reference material•Information and tutorials
www.CareCoreNational.com
Access Authorization Details Online
Online Prior Authorization RequestTo submit a prior authorization request or access authorization details online, first time users will need to register on the Provider Web Portal.
Provider Online Registration
Provider Online Registration
Provider Online Registration
Provider Online Registration
xxx
xxx
Provider Online Registration
Provider Web Portal
Prior Authorization Online RequestReferring providers can submit a prior authorization request online by logging into the Provider Web Portal and selecting “Request a clinical certification.”
866-665-8341
Prior Authorization Online Request
Below is a sample of the Provider Portal view.
Referring Provider Access
Rendering providers can verify the status of an existing prior authorization request. Information needed for a search:
• Provider ID or Tax ID• Patient ID and Date of Birth or Authorization Number or
Case NumberOr Call 1 (866)-668-8295
Rendering Provider Access
Rendering Provider Access
Physicians may review the CareCore Evidence Based Guidelines at any time.
The Evidence Based Guidelines used in rendering medical necessity
decisions is posted publicly at www.CareCoreNational.com.
CareCore National Clinical Criteria
Avera Health Plans online resources which includes a link to CareCore’s website.
Additional Information
Resources found on Avera Health Plans Website:
www.AveraHealthPlans.com and click Provider Login
CareCore National Website Link
Reference Guide
Quick Access Phone Reference Sheet
Quick Access Online Reference Sheet
Frequently Asked Questions Document
Additional Information
Additional Information
Questions?