chiropractic services utilization management program for … · 2019-02-21 · if clinical...
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© 2016 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.
Chiropractic Services Utilization Management Program for Health Partners Plans
Provider Orientation
2
Company Highlights
3k+ employees, including 1k clinicians
100M members managed nationwide
Clients ranging in size from <10k lives
to >10M lives
Headquartered in Bluffton, SC Offices across the US including:
Colorado Springs, CO
Franklin, TN
Greenwich, CT
Lexington, MA
Melbourne, FL
Plainville, CT
Sacramento, CA
12M claims processed annually
SHARING
A VISION AT THE
CORE OF CHANGE.
3
Integrated Solutions
CARDIOLOGY
46M lives
RADIOLOGY
65M lives
MUSCULOSKELETAL
34M lives
SLEEP
13M lives POST-ACUTE CARE
145k lives
MEDICAL ONCOLOGY
14M lives
RADIATION THERAPY
22M lives
LAB MANAGEMENT
19M lives
SPECIALTY DRUG
100k lives
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Our Clinical Approach
• 190+ board-certified medical
directors
• Diverse representation of medical
specialties
• 450 nurses with diverse
specialties and experience
• Dedicated team of chiropractic
clinical peer reviewers.
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Clinical Platform
Chiropractic
Internal Medicine
Pediatrics
Sports Medicine
OB/GYN
Cardiology
Nuclear Medicine
Anesthesiology
Radiation Oncology
Sleep Medicine
Oncology/Hematology
Surgery
• General
• Orthopedic
• Thoracic
• Cardiac
• Neurological
• Otolaryngology
• Spine
Radiology
• Nuclear Medicine
• Musculoskeletal
• Neuroradiology
Multi-Specialty Expertise
• American College of Cardiology
• American Heart Association
• American Society of Nuclear Cardiology
• Heart Rhythm Society
• American College of Radiology
• American Academy of Neurology
• American College of Chest Physicians
• American College of Rheumatology
• American Academy of Sleep Medicine
• American Urological Association
• National Comprehensive Cancer Network
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Organic Evidence-Based Guidelines
The foundation of our solutions:
• American College of Therapeutic Radiology and
Oncology
• American Society for Radiation Oncology
• American Society of Clinical Oncology
• American Society of Colon and Rectal Surgeons
• American Academy of Orthopedic Surgeons
• North American Spine Society
• American Association of Neurological Surgeons
• American College of Obstetricians and Gynecologists
• The Society of Maternal-Fetal Medicine
Aligned with National Societies
Dedicated
pediatric
guidelines
Contributions
from a panel
of community
physicians
Experts
associated
with academic
institutions
Current
clinical
literature
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Service Model
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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 dedicated to
specific providers 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.
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Chiropractic Services
Utilization Management Program
for Health Partners Plans
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Chiropractic Services Policy
Description Criteria Limitations Admin.
Guidelines
The Medical Assistance
Program provides payment for
specific chiropractors’ services
rendered to eligible recipients
by chiropractors enrolled as
providers under the program.
Chiropractic care is considered
covered for manual manipulation
of the spine to adjust misaligned
or displaced vertebrae.
The following are not covered:
• Treatment other than manual
manipulation of the spine to
correct a subluxation
• Physical therapy
• Traction procedures
• Physical examinations
• Consultations
• Inpatient services
Submission of a Chiropractic
Services Treatment Plan form is
required.
Treatment frequency should be
consistent with the severity of
the patient’s condition.
eviCore will begin accepting requests on 7/25/2016 for dates of service
8/1/2016 and beyond
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Program Overview
Authorization for treatment applies to services:
• Starting with the patient’s initial visit
It is the responsibility of the rendering provider to request
precertification for services.
Applicable Membership
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Authorization is required for members enrolled in the following programs:
• HealthChoices Medicaid
Members who do not require authorization are
• The Children’s Health Insurance Program (CHIP)
• Health Partners Medicare*
*Authorization of Chiropractic Services will be effective 1/1/2017 for Health Partners Medicare
Two ways to request authorization:
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Authorization Requests
888-565-4225
For questions regarding the
Chiropractic Services Treatment Plan
form, you may call eviCore’s Customer
Service at: 877-531-9139
http://www.lmhealthcare.com/
Available 24/7 and the quickest
way to submit authorization and
check existing case status.
To register, call 877-531-9139
WEB
FAX
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Needed Information
Member Member ID
Member name
Member address
Date of birth (DOB)
Rendering Provider Rendering provider name
Tax identification number (TIN)
Fax number
Street Address
i Requests All clinical findings
requested on the
Chiropractic Services
Treatment Plan form,
related to spinal
conditions, are required
for review.
If clinical information is needed, please be able to supply:
• Patient’s subjective complaints, objective examination findings, and level of function
• Information from the Chiropractic Services Treatment Plan form
• Office notes are optional as the needed clinical information is contained in Chiropractic
Services Treatment Plan form
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Chiropractic Services Treatment Plan
• The Chiropractic Services Treatment Plan is designed to assist with the
submission of patient and practitioner information for medical necessity
review.
• This treatment plan form should be completed by the practitioner during the
initial consultation and treatment planning, collecting the clinical information
to allow for ease of submission.
• The Chiropractic Services Treatment Plan form is available through our web
portal and is specific to Chiropractic services.
• Services should not be requested more than 7 days prior to the proposed
Start Date. Requesting care too far in advance does not allow you to report
up-to-date clinical findings.
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Chiropractic Services Treatment Plan Form
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Chiropractic Services Treatment Plan
Patient & Provider Information Member ID
Member name
Member Address
Date of birth (DOB)
Rendering Provider Rendering provider name
Tax identification number (TIN)
Fax number
Street Address
• Requests for authorization must be submitted on an eviCore
Chiropractic Services Treatment Plan.
• Patient and Rendering Provider demographic information is
completed for you when you submit authorization requests via
the Web.
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Chiropractic Services Treatment Plan
Clinical Findings All clinical findings on the Chiropractic Services Treatment Plan
form, referenced above, related to spinal conditions, are required
for review.
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Chiropractic Services Treatment Plan
Clinical Findings All clinical findings on the Chiropractic Services Treatment
Plan form, referenced above, related to spinal conditions,
are required for review.
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Review Determination Outcomes
• It is our business practice to complete requests
within 2 business days from the receipt of complete
clinical information.
• Authorizations are typically good for 30 calendar
days from the date of determination.
Approved Requests:
• Faxed to rendering provider
• Mailed to the member
• Information can be printed on demand from the
eviCore Provider Portal, Landmark Connect
Delivery:
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Review Determination Outcomes
• Communication of denial determination
• Communication of the rationale for the denial
• How to request a Peer Review
Denied Requests:
• Faxed to the rendering provider
• Mailed to the member
• Determination letters are available on Landmark
Connect
Delivery:
• Rendering Chiropractors will have the option to
speak with an eviCore clinical peer reviewer during
the adverse determination process. Details will be
provided in the Review Determination Letter.
Peer-to-Peer Review:
• eviCore healthcare is not delegated to handle
clinical appeals.
• Your determination letter will provide you with
information regarding how to appeal denied
services with Health Partners Plans.
Appeals:
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Approved Time Period
• Care is typically approved for 30 calendar days from the requested start date and
allows the practitioner to assess the patient’s response to treatment. The duration
of the authorization is known as the Approved Time Period.
• Visits should be spread throughout the authorized duration to avoid a gap in care
at the end of the Approved Time Period.
• Submit an updated treatment plan to request continuing care if more visits are
medically necessary after the Approved Time Period expires.
o If the member has a setback or complication, you may request additional visits
within an existing Approved Time Period. To do so, you must submit a new
Chiropractic Services Treatment Plan form with updated clinical findings.
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Date Extension
• An extension may be necessary due to unforeseen delays, such as your patient’s
inability to attend all scheduled visits.
o One date extension, up to 30 days beyond the authorization end date, will be allowed
per authorization for patients aged 21 years and over.
o Two date extensions, up to 30 days each beyond the authorization end date, will be
allowed per authorization for patients under the age of 21.
• You may submit a Date Extension by using the Date Extension Request e-Form
on the Provider Portal, or download the Date Extension Request Form and fax it
to 888-565-4225.
• You must request your date extension within 30 days from the End Date of the
Approved Time Period if you want to extend.
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Provider Resources
Web-Based
Services
Documents
Provider Resources: Customer Service
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8:00 AM - 5:00 PM (Eastern Time): (877) 531-9139
• Obtain assistance with web registration
• Check the status of an existing authorization
• Discuss questions regarding authorizations and case decisions
• Obtain information specific to treatment submissions, extensions
and utilization management policies
eviCore fax number: (888)-565-4225
Customer Service
Department
Web-Based
Services
Documents
Provider Resources: Web-Based Services
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Customer Service
Department
Landmark Connect
For assistance with the Provider Portal, contact Customer Service at
(877)-531-9139.
Our Provider Portal allows you to: • Complete self-registration
• Request authorization and check status online – 24/7
• View Determination Letters
• View Program Specific Information, including FAQ documents
and other program-related material
Web-Based
Services
Documents
Provider Resources: Implementation Document
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Customer Service
Department
Please visit Landmark Connect to access the following program materials.
Provider Portal Site:
• Chiropractic Utilization Management Guide
• Frequently Asked Questions resource document
To obtain a copy of this presentation, please contact
Program Criteria:
• Chiropractic Guidelines – Chiropractic Services
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Thank You.