musculoskeletal precertification program for aetna · nuclear medicine anesthesiology radiation...
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© 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.
Musculoskeletal Precertification Program for Aetna
Provider Orientation
Company Highlights
3K+ employees including 1K clinicians
90M members managed nationwide
12M claims processed annually
Headquartered in Bluffton, SC Offices across the US including:
• Melbourne, FL
• Plainville, CT
• Sacramento, CA
• Burlington, MA
• Colorado Springs, CO
Franklin, TN
• Greenwich, CT
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SHARING A VISION
AT THE CORE OF CHANGE.
All solutions operate on a single platform
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Integrated Solutions
CARDIOLOGY
46M lives
RADIOLOGY
65M lives
MUSCULOSKELETAL
19M lives
SLEEP
13M lives
POST-ACUTE CARE
145K lives
MEDICAL ONCOLOGY
12M lives
RADIATION THERAPY
19M lives
LAB MANAGEMENT
19M 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 nursing and physician
teams by specialty for
Cardiology, Oncology, OB-GYN,
Spine/Orthopedics, Neurology,
and Medical/Surgical
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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
Multi-Specialty Expertise
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Service Model
The Client Service delivery team is responsible for high-level service delivery to our
health plan clients as well as ordering and rendering providers nationwide
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Client Service Delivery Team
Best Colors
Client service
representatives
are cross-trained to
investigate escalated
provider and health
plan issues.
Client Service
Representatives
Client service managers
handle complex issues
and serve as the primary
contact for account
executives, health plans,
and high-profile provider
clients.
Client Service
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
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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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Musculoskeletal Precertification
program for Aetna
eviCore will begin accepting requests on December 14, 2015 for dates
of service January 1, 2016 and beyond
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Program Overview
Precertification applies to
services that are:
• Outpatient
• Inpatient*
• Elective/non-emergent
Precertification
does not apply to services
that are performed in:
• Emergency room
• 23-hour observation
* If an approved procedure is being performed in an inpatient setting, the
provider will need to wait 48 hours and contact Aetna directly to have the
inpatient admission approved.
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Precertification Required:
To find a list of CPT
(Current Procedural Terminology)
codes that require precertification
through eviCore, please visit:
www.medsolutions.com/implementation/Aetn
aMSK
Joint Surgery
• Hip and Knee arthroplasty
Interventional Pain
• Spinal injections
Applicable Membership
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Authorization is required for all Aetna members enrolled in the following
programs:
• HMO
• HNO
• Medicare
• PPO
• Self-insured groups that opt out of program do not require precertification
Confirm eligibility on the web portal to determine if precertification is
required: https://myportal.medsolutions.com
How to request precertification:
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Precertification Requests
Or by phone:
Nationwide:
888.693.3211
New York market:
888.622.7329
Northern New
Jersey market:
888.647.5940
8:00 a.m. to 9:00
p.m. (EST)
Monday - Friday
Fax option: 888.693.3210 | Fax forms available at: www.medsolutions.com
WEB
https://myportal.medsolutions.com
Available 24/7 and the quickest
way to create precertification and
check existing case status
Clinical Review Notification
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Peer-to-Peer
MD Review
Real-Time Approval
Clinical Review
IVR
Appropriate
Decision
Clinical reviews submitted through the web portal may achieve
real-time decision making
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Needed Information
Member Member ID
Member name
Date of birth (DOB)
Facility Facility name
National provider identifier (NPI)
Tax identification number (TIN)
Street address
Rendering Provider
Physician name
National provider identifier (NPI)
Tax identification number (TIN)
Fax number
Requests
CPT code(s) for
requested procedure
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
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Precertification Outcomes Approved Requests: • It is our business practice to complete
requests within 2 business days from
the receipt of complete clinical
information.
• Decision is emailed or faxed to the
rendering provider and the facility once
medical necessity is met.
• Notification is mailed to the member.
• Can be printed on demand from the
eviCore Web portal.
• Authorizations are good for 90 days
from date of determination.
• Providers must wait 48 hours from the
determination to contact Aetna to
receive inpatient admission approval.
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Precertification Outcomes: Denied Requests
Reconsideration
• Faxed to rendering provider
• Mailed to the member
• Notification is faxed to the facility
Delivery:
• A provider may request a same specialty expertise peer-
to-peer conversation. • Must be requested within 14 calendar days from the
denial
• May be scheduled by calling the market specific phone
number, please refer to the quick reference guide
• Peer-to-peer conversations on denied services for
Medicare members are educational only.
Peer-to-Peer Review:
Appeals:
• Additional clinical information can be provided without
the need for a physician to participate.
• Must be requested within 14 calendar days from the
denial
• Medicare members follow CMS guidelines
• Clinical appeals must be initiated in writing through
Aetna
• Notification letter will include how to appeal
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Special Circumstances
Retrospective Procedures:
• eviCore will conduct retrospective reviews if
requested within 14 calendar days following the
date of service
• Service must have been urgent and medically
necessary.
Outpatient Urgent Procedures:
• Contact eviCore by phone to request an expedited
precertification review and provide clinical
information
• Urgent cases process within 4 hours
• Medically urgent requests are defined as
conditions that are a risk to the patient’s life,
health, ability to regain maximum function, or the
patient is having severe pain that required a
medically urgent procedure.
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Provider Resources
Client Services
Department:
Documents
Provider Resources: Web-Based Services
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https://myportal.medsolutions.com
• Request authorizations and check case status online
• Print case summary reports
• Attach clinical documents during and after case creation
• Auto save – no data lost
• Export and print work lists
• View cases by individual user and office
To speak with a Web Specialist, call (800) 575-4594
Web-Based
Services
Pre-Certification
Call Center
Client Services
Department:
Documents
Provider Resources: Precertification Call Center
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Nationwide: 888.693.3211
New York market: 888.622.7329
Northern New Jersey market: 888.647.5940
8:00 AM - 9:00 PM EST
• Obtain precertification or check the status of an existing case
• Discuss questions regarding precertification and case decisions
• Change facility or CPT Code(s) on an existing case
eviCore fax number: (888) 693-3210
Pre-Certification
Call Center
Web-Based
Services
Client Services
Department:
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Client Services Department
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• Eligibility issues (member, rendering facility, and/or ordering
physician)
• Questions regarding accuracy assessment, accreditation, and/or
credentialing
• Issues experienced during case creation
• Request for an authorization to be resent to the health plan
Client Services
Department:
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Program Information
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Aetna site - includes all pertinent program documents:
http://www.MedSolutions.com/implementation/AetnaMSK
• CPT code list of the procedures that require precertification
• Quick reference guide
• eviCore clinical guidelines
• FAQ documents and announcement letters
To obtain a copy of this presentation, please contact the
Client Services department at [email protected]
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Web Portal Services
New Web Portal Services
https://myportal.medsolutions.com
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MAIN MENU
How to Register
Getting Started
- Case Creation
New Web Portal
Services – Help!
Self Service at Your Fingertips!
It’s Simple
It’s Available 24/7
Creating an Account
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Before continuing, please read to determine what account type to register
under; then click Register Now to continue.
User registration
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Determine the appropriate user
type in the Account Type
dropdown; (Physician, Facility,
Health Plan or Billing Office)
Fill in all required information
marked with an asterisk*
Enter the Provider for which you
are associated, using Name and
TIN
Select the Next button
Click Find and select provider
NOTE: Your email address will be
your user name
User registration continued……
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Review all information for accuracy and click
Submit Registration.
User registration continued……
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Accept Terms and Conditions and click Submit.
User registration continued……
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You will receive a message confirming your registration is successful,
and you will also receive an email to create your password.
User registration continued……
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Your password must be as least 8
characters long and contain the following:
• Uppercase letters
• Lowercase letters
• Numbers
• Characters (i.e., ! ? *)
Logging in
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Once you have created your
password, you will be taken back to
the Login Page.
Type in your Email Address
and Password
Check I Agree to the HIPAA
Disclosure Agreement. The
Login button will turn green.
Click Login
announcements
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Home tab
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The Home Page will have two worklists:
My Pending Worklist & Recently
Submitted Cases.
My Pending Worklist
You can save the case information (if
you have to stop at any point) and
come back to it at a later time.
You no longer have to start over
with a case!
Additional clinical can now be
added to a pending case after
submission without having to fax!
Recently Submitted Cases
Cases that are pending review and/or
Cases recently approved or denied
HOME
Home tab continued…..
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Cases Pending for Case Details and Surveys
will be deleted after 7 calendar days. You also
have the option to manually delete a case in
My Pending Worklist (prior to 7 days), if the
case is no longer needed.
Page scroll Number of cases
Recently Submitted Cases will show for a
2 day time span. The dates can be edited
for any 2 day span requested.
Home tab continued…..
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Action icons: Hide My Pending
Worklist, Reset to Default View,
Printer Friendly Format, Export to
Excel, and Help. Search Recently Submitted
Cases by entering a Start Date
and End Date. Clear filters and
Refresh Data options
The “Only My Portal Cases” checkbox is
checked as a default. Un-check to see
cases other than cases you created.
(cases will be under their original TIN only)
Search/start case – member lookup
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To conduct a Patient Lookup, first select the
appropriate insurance company from the Insurer
drop down. Next, enter the Member ID or First
Name, Last Name and Date of Birth for the result to
be returned.
For Case/Auth Lookup, you
will only need to enter the
Case ID or Auth Number at
the bottom of the page and
hit Search.
Tip: Hit the
tab key to
activate the
Search button
Search/start case – member lookup
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If a partial ID is put in the search box, a
list of members will populate. A member
can be selected once the member is
highlighted blue. Please make sure you
select the correct patient by verifying the
patients name and DOB before clicking
Create Case.
If there are cases associated with the
patient they will populate once the patient
is selected. Double click on a case ID in
the Patient History to open that case.
Search/start case – cpt/icd codes
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Search/start case – ordering physician
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Search the Physician by Name or Tax ID# or NPI. For best results, use NPI to
search (in lieu of Tax ID) and for Health Plans that require NPI.
Once the correct physician
displays, select by clicking on the
record, then hit Save & Next.
*Please note, the “Use Referring
Physician as Requested Facility”
button is for outpatient requests
only.
Search/start case – select facility
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Choose a facility from the list by highlighting it
blue, or search a facility by clicking the Search
Facility button and enter facility Name or Tax ID.
Search by NPI (in lieu of Tax ID) for the Health
Plans that require NPI.
Once the correct facility
is selected, then click the
Save & Next button.
For in-office-procedure,
click the Look-up IOP
button and choose from
the list.
Search/start case – review and submit
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You can edit the CPT/ICD, Physician and Facility
information by clicking the icon.
Once you’ve reviewed
the case details, click
Submit.
NOTE: The case details cannot be changed once you press the “Submit” button!
Survey Questions
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Survey Questions
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Previously Answered Questions –
Review History
Survey has been completed
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Survey Has been Completed
Survey has been completed
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Providing clinical information
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Depending upon the health
plan, specific options for
providing clinical will be
available:
You will then be asked to
attached the electronic clinical
information available; then
select the Continue button.
Providing clinical information continued……
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You can select to
attach clinical notes,
or documents from
your computer, by
clicking Browse and
selecting the correct
file(s).
Hit Apply to continue or Cancel to add
additional information at a later time.
Providing Clinical Information Continued……
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Once you click Apply you will receive the
message that your documentation has
been accepted and the case has been
immediately sent for medical review which
will show up on the Worklist. Click OK.
Case summary page – pending case example
Case/Authorization number
Place Of Service & Initial
Service Request Fields
Case summary page – approved case example
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Authorization Number and
Auth Effective Date
Auth End Date
(expiration) Case Status
Cigna MSK CPT used - 64479
Place Of Service & Initial
Service Request Fields
Account settings – options tool
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Change Password
Set up a new password for your
account
Account Info
For Account Maintenance Options
Update User Information; Address,
Phone Number and Physician’s Name
Case Preferences
Set up preferred provider Tax ID’s for
Physician and Facility
OPTIONS TOOL
The Options Tool gives you the option
to change your password, update user
information and set preferred
preferences.
Preferences – physician / facility
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Adding a preferred Tax ID will allow you to view
the summary of cases submitted for those
providers. Click Physician or Facility to search a
Tax ID, then click Add. You can delete an added
Tax ID by clicking the X.
Before proceeding you must confirm you are
authorized to access Protected Health
Information (PHI), by clicking the check box *.
Once all preferred Tax IDs have been entered,
be sure to hit Save.
Web portal - help
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Should you need assistance while navigating
the portal:
Click Online Chat
Call a Web Support Specialist at
(800) 575-4594 (Option 2)
Or
Click the Contact Us link
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Thank You!