Prior Authorization of Advanced Imaging and …...260 board-certified medical directors • Diverse representation of medical specialties • 450 nurses with diverse specialties and
Prior Authorization of Advanced Imaging and Cardiology Services for Highmark
Provider Orientation
Presenter
Presentation Notes
Thank you for joining, my name is ______. I’m a Client & Provider Engagment Manager with eviCore healthcare, and I will be your presenter. Today we’ll be reviewing the Highmark Advanced Imaging and Cardiology Svcs Prior Authorization Program. Attendees are automatically place on mute to reduce background noise due to a large # of attendees & to reduce background noise so everyone is able to hear today’s presentation. We’ll open the chat feature for questions at the end of the presentation. Today’s Agenda will be… An overview of eviCore healthcare An overview of our evidence based guidelines Review the specifics of the Highmark Advanced Imaging and Cardiology Services program. We’ll review the Highmark web portal, NaviNet, which is the quickest way to submit authorization requests Next we’ll review Provider Resources Then we’ll review the new privilegining program and processes And finally we’ll ask you to answer a few polling questions about todays presentation and then will ask you to send us any questions you have via the chat feature during the end of the presentation. Please hold all chat questions until the end of the presentation.
Let's begin with a company introduction. eviCore is a specialty benefit management company, managing the quality and use of inpatient & outpatient procedures through multiple programs. CareCore National was founded in 1994 and MedSolutions in 1995. They became one company under our new name eviCore in 2015.
eviCore currently manages 9 comprehensive solutions for clients and providers nationwide, all of which are listed on the list here. You may have worked with eviCore previously with one of these solutions with Highmark or one of the other approximately 100 HPs which eviCore works with. eviCore is currently managing Radiation Therapy, Lab Mgmt, & MSK for HMK and will add Radiology & Cardiology solutions effective Jan. 1st.
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Our Clinical Approach
Presenter
Presentation Notes
It is important you understand our clinical approach at eviCore and the level of clinical expertise we maintain to effectively manage all of our various programs.
• 260 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
We not only have Board Certified Medical Directors in the field of Radiology & Cardiology but also have dedicated teams for Oncology, Orthopedics, Internal Medicine, Neurology, etc. If at any time one of your physicians needs to speak with a Medical Director, we do have physicians available in the same specialty / area of expertise. Radiology and Cardiology are eviCore’s largest solutions and eviCore has more than 500 radiology & cardiology trained nurses and more thank 150 radiology & cardiology physicians on staff.
The foundation of our solutions:
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Evidence-Based Guidelines
Aligned with National Societies
Dedicated pediatric guidelines
Contributions from a panel of community physicians
Experts associated with academic institutions
Current clinical literature
• American College of Therapeutic Radiology and Oncology
• American Society for Radiation Oncology
• American Society of Clinical Oncology
• American Academy of Pediatrics
• 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
• 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
Presenter
Presentation Notes
Our clinical guidelines are some of the most comprehensive in the industry & are aligned with various National societies, some of which are posted on this slide. They are developed thru Multiple sources of input including feedback from health plan partners Contributions from a panel of community physicians Experts associated with academic institutions Current clinical literature There are Dedicated pediatric guidelines Based on Clinical Presentation Compliant with Medicare NCDs/LCDs
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Advanced Imaging and Cardiology Services Prior Authorization Programfor Highmark
Presenter
Presentation Notes
Next we will be discussing the details of the Advanced Imaging and Cardiology Svcs Prior Authoriztion program for Highmark.
eviCore will begin accepting requests on Dec. 17, 2018 for dates of service Jan. 1, 2019 and beyond
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Program Overview
Prior authorization applies to services that are:
• Outpatient• Elective / Non-emergent• Diagnostic
Prior authorization does not apply to services that are performed in:
• Emergency room• Inpatient• Observation
It is the responsibility of the ordering provider to request prior authorization approval for services.
It is the responsibility of the rendering provider to verify that the necessary authorization has been obtained before providing the service.
Presenter
Presentation Notes
eviCore healthcare will began accepting prior authorization requests on December 17, 2018 for studies to be performed January 1, 2019 and beyond. The process applies to Outpatient, Elective Diagnostic Imaging. This means that any studies perform in an emergency room, as an inpatient or patient admitted for observation stay does NOT require prior authorization. It is the responsibility of the ordering provider to request prior authorization approval for services. It is the responsibility of the rendering provider to verify that the necessary authorization has been obtained before providing the service.
Applicable Membership
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Authorization by eviCore is required for Highmark members in Pennsylvania, Delaware and West Virginia enrolled in the following programs:• Commercial Fully Insured• Commercial Self Insured• Medicare Advantage (PA and WV)• Affordable Care Act• Administrative Services Only (select groups) • Children’s Health Insurance Program (CHIP) (PA only)• Out of Area select ASO groups
Members who do not require prior authorization are:• All other Out Of Area (OOA)
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.
*Additional Advanced Imaging & Cardiology Services modalities in eviCore’s program scope.
Presenter
Presentation Notes
Prior Authorization is required for certain advanced imaging and Cardiology services which are listed on the left hand side of the slide. Modalities which previously did not require Prior Authorization but will now require Prior Authorization effective January 1st are bolded. Those new modalities are Nuclear medicine, Echocardiograpy & Diagnostic Heart Catheterization. On the right hand side of the slide is a link to the eviCore/HMK provider resource page or implementation site. Please reference this site to view a list of all CPT codes which require prior authorization.
Or by phone*: 888-564-5492 7:00 a.m. to 7:00 p.m. ESTMonday - Friday
Fax* option: 800.540.2406 Fax forms available at www.evicore.com
WEB
NaviNet® Available 24/7 and the quickest way to create prior authorizations and check existing case status
Presenter
Presentation Notes
The web portal is the quickest, most efficient way to submit authorizations and check case status and is available 24/7. By utilizing Navinet, you have real-time access to patient authorization and eligibility information as well as the ability to submit requests at a time that best fits your schedule. Using the Web Portal for requests is significantly quicker than phone requests. You will now have the ability to upload PDF/Word files electronically with additional clinical documentation when a case is sent for medical review - no more faxing You may also submit requests via phone and fax. Upload electronic PDF/Word files with additional clinical documents when a case is sent for medical review - no more faxing!
Cases submitted via web & phone enables potential for immediate authorization w/ our Predictive Intelligence Model and Clinical Decision Support. Cases which require clinical review will first be reviewed by an eviCore nurse. The nurse has the ability to approve the case or if unable to approve will pass along to an eviCore Medical Directors to further review. eviCore medical directors may approve or deny requests. Only an eviCore MD can deny any request for services. In the event of an adverse determination a clinical consultation is always available to providers. These can be scheduled via phone or on eviCore.com. Clinical consultations procedures will be by a provider with same specialty expertise as the requesting provider and depending on the plan type may lead to the denial being overturned or upheld. We’ll get into the difference of commercial vs. Medicare clinical consultations in a few minutes.
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Needed Information
MemberMember ID
Member nameDate of birth (DOB)
Rendering FacilityFacility nameNational provider identifier (NPI)Tax identification number (TIN)Street address
Referring/Ordering PhysicianPhysician name
National provider identifier (NPI)Tax identification number (TIN)
Fax number
i RequestsCPT code(s) for requested imaging
The appropriate diagnosis code for the working of differential diagnosis
If clinical information* is needed, please be able to supply:
• Prior tests, lab work, and/or imaging studies performed related to this diagnosis
• The notes from the patient’s last visit related to the diagnosis
• Type and duration of treatment performed to date for the diagnosis
*Clinical information may be uploaded electronically via the Provider Portal
Presenter
Presentation Notes
In order to be best prepared for requesting a study some items to have available would be the member information; ID, name DOB; the ordering physician information; the rendering site information, the CPT and ICD-10 codes as well as any clinical information available. If clinical information* is needed, please be able to supply: • Prior tests, lab work, and/or imaging studies performed related to this diagnosis • The notes from the patient’s last visit related to the diagnosis�• Type and duration of treatment performed to date for the diagnosis *Again, clinical information may now be uploaded electronically via NaviNet. We’ll cover this process during our Web Portal Services overview
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Prior Authorization Outcomes
• All requests are processed within 2 business days after receipt of all necessary clinical information.
• Authorizations are typically good for 60 days from the date of determination.
• Highmark will honor existing prior authorizations for continuity of care on claims for advanced imaging & cardiology services which 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 and • Mailed to the member• Information can be printed on demand from the
Highmark provider web portal
Delivery:
Denied Requests:
Delivery:
Presenter
Presentation Notes
EviCore will process all requests within 2 business days after receipt of all necessary clinical information. the clock does not start on the 2 days until after any request for additional information has been received. That is why it is most important to provide all the clinical information on initial request so as to avoid any delays in getting that patient their study Authorizations are typically good for 60 days. Highmark will honor existing prior authorizations for continuity of care on claims for advanced imaging & cardiology svcs which overlap during the transition to the new program All approved authorizations are faxed to the ordering provider & mailed to the member. This information can be printed on demand from NaviNet. There may be instances where the request will be denied. We will contact you and give you the reason (rationale) for the denial (which you can find on the web portal right away), and how to request a Peer Review and appeal rights. We fax the denial to the ordering physician and mail a copy to the member. This information can also be printed on demand via NaviNet.
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Prior Authorization Outcomes- Commercial
• 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.
• Clinical Consultations can be scheduled at a time convenient to your physician
• Commercial members only
Clinical Consultations:
Presenter
Presentation Notes
For Commercial members both reconsiderations & peer-to-peer reviews are available for any requests which resulted in a denial. A reconsideration is when additional clinical information can be provided without the need for a physician to participate Reconsiderations must be requested on or before the anticipated date of service A Peer-to-Peer review is also available. 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.
• 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 Consultations
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Presentation Notes
A pre-decision Consultation is for medicare members. If your case requires further clinical discussion for approval, we welcome requests for clinical determination discussions from referring physicians. In certain instances, additional information provided during the pre-decisions consultation is sufficient to satisfy the medical necessity criteria for approval. However, if the request is denied, the decision is final and cannot be overturned. **At no time will eviCore deny the right for external physicians to speak with our physicians. However, having a conversation with an eviCore medical director may not affect the outcome.
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Special Circumstances
Medical Necessity Appeals:
• eviCore will process first level provider appeals for Commercial members.
• Requests for appeals must be submitted to eviCore within;• West Virginia & Delaware: 365 calendar days of the initial
determination.• Pennsylvania: 180 calendar days of the initial determination.
• Requests will be considered an appeal if;• A clinical consultation or reconsideration was completed.• An appeal is formerly requested• Prior to 180 calendar days• Appeals after 180 calendar days will not be processed and will
be directed to Highmark.• 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 all other members.
• Appeals for services that were denied before the new advanced imaging and cardiology services program goes into effect must be submitted to NIA.
Presenter
Presentation Notes
Moving onto Special Circumstances… eviCore will process first level provider appeals for Commercial members. Requests for appeals must be submitted to eviCore in West Virginia & Delaware within 365 calendar days of the initial determination & in Pennsylvania within 180 calendar days of the initial determination. Requests will be considered an appeal if; A clinical consultation or reconsideration was previously completed, An appeal is formerly requested & it is submitted prior to 180 calendar days. Appeals requested after 180 calendar days will be directed to Highmark. 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 all other members. Appeals for services that were denied before the new program goes into effect must be submitted to NIA.
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Special Circumstances
Outpatient Urgent Studies:
• Urgent requests may be submitted on the portal or by phone 7:00 AM - 7:00 PM (EST): (888) 564-5492
• In order to submit an urgent request online, providers must upload all supporting clinical documentation during case initiation.
• If submitted by phone, 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.
Retrospective Studies:
• 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 prior to 1/1/19 must be submitted
to NIA.
Urgent care is any request for medical care or treatment with respect to which the application of the time periods for makingnon-urgent care determinations could result in the following circumstances:
• Could seriously jeopardize the life or health of the member or the member's ability to regain maximum function, based on a prudent layperson's judgment, or
• In the opinion of a practitioner with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. (National Committee for Quality Assurance [NCQA] HUM8)
Presenter
Presentation Notes
Retro requests are accepted & must be submitted within 730 business days following the date of service. Requests fter 730 business days will be administratively denied. Retros can be submitted via phone or fax & are reviewed for medical necessity. Turnaround time for eviCore to render a decision is 30 calendar days. All retro requests for dates of service prior to 1/1/19 must be submitted to NIA. Urgent requests may be submitted on the portal or by phone. In order to submit an urgent request online, providers must upload all supporting clinical documentation during case initiation. If submitted by phone, request an expedited outpatient prior authorization review and provide clinical information. Contractually all urgent outpatient cases will be reviewed within 24 hours not to exceed 72 hours of the request. However, the eviCore standard is w/in 4 hours. Urgent Care is defined as request for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could result in the following circumstances… Could seriously jeopardize the life or health of the member or the member's ability to regain maximum function, or In the opinion of a practitioner with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request
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NaviNet Services
Presenter
Presentation Notes
Next we will be discussing the Highmark provider web portal, NaviNet, which as I stated earlier is the quickest, most efficient, and easiest way to obtain an authorization.
NaviNet Member Eligibility and Benefits Inquiry
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Please make sure you are utilizing NaviNet to see if a member requires authorization for outpatient Advanced Imaging and Cardiology Services.
Presenter
Presentation Notes
Please make sure you are utilizing Highmark’NaviNet to submit Advanced Imaging and Cardiology Services authorization requests. You may select Eligibility and Benefits Inquiry to check if authorization is required.
NaviNet Member Eligibility and Benefits Inquiry
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When searching for benefits in NaviNet, you can enter a Member ID or First Name, Last Name and Date of Birth.
Presenter
Presentation Notes
This is the Eligibility and Benefits Patient Search function on NaviNet. When searching for benefits, you may enter a Member ID or First Name, Last Name and Date of Birth.
NaviNet Member Eligibility and Benefits Inquiry
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A category for Advanced Imaging and Cardiology Services is located on the Eligibility and Benefits screen in NaviNet to indicate if authorization is required.
Advanced Imaging Ind. NO indicates no outpatient authorization is required.
Presenter
Presentation Notes
A category for Advanced Imaging and Cardiology Services is located on the Eligibility and Benefits screen in NaviNet to indicate if authorization is required. If Advanced Imaging Ind. Is “NO” this indicates no outpatient authorization is required.
Single-Sign On for Highmark Providers / NaviNet
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Select Authorization Submission from the Plan Central page to start the request
Presenter
Presentation Notes
To initiation an authorization request on NaviNet, please select “Auth Submission” from the Plan Central page
Single-Sign On for Highmark Providers / NaviNet
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Select the Referred from Billing Provider associated with the NaviNet office account.
Presenter
Presentation Notes
Select the Referred from Billing Provider associated with the NaviNet office account.
Single-Sign On for Highmark Providers / NaviNet
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Select the Referred from Service Provider and the Proposed Date of Service. Enter the Member information and select the Category & Service.
Presenter
Presentation Notes
Step 1 – You will select a Referred from Service Provider and the proposed date of service Step 2 – Locate the Member using the Member ID with DOB and Member First and Last Name Step 3 – Between 12/17 & 12/31 you will be required to Select the Category and Service type. After Jan. 1, 2019 , for eviCore requests, ANY IMAGING CATEGORY can be selected for ANY advanced imaging and cardiology procedures.
Single-Sign On for Highmark Providers / NaviNet
Select the Referred to Provider
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Presentation Notes
Select the Referred to Provider and verify the provider network is considered at the in-network level for the member’s benefit plan.
Single-Sign On for Highmark Providers / NaviNet
Select up to 2 diagnosis codes, enter the remaining required fields and then Submit
Presenter
Presentation Notes
Please select up to 2 diagnosis codes, as well as any remaining required fields and then click Submit
Contact Information
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Enter the ordering practitioner name, who to contact from the ordering practice and appropriate information for the point of contact individual.
Presenter
Presentation Notes
You’ll see a popup asked you to review the fax and phone numbers presented for accuracy. Change as necessary and click CONTINUE to confirm they are correct. Changes only apply to this specific case. If you wish the change to be permanent, please contact the HP.
Clinical Details
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Select the CPT and Diagnosis codes. Both fields in the CPT code and diagnosis code section are searchable by drop down lists - once you select one and click outside the box the other
populates.
Presenter
Presentation Notes
Select the CPT and Diagnosis codes. Both fields in the CPT code and diagnosis code section are searchable by drop down lists - once you select one and click outside the box the other populates. Refer to - CPT Code List by Category and Service Type and New CPT Code List
Verify Service Selection
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Click continue to confirm your selection.
Presenter
Presentation Notes
Confirm your selections, you have the ability to edit and correct the information by selecting the “Edit” or “Change” buttons
Verify Service Selection
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To request additional procedures for the same member, site, and date of service, select “Yes” & Submit.Enter the Procedure Code being requested. Additional codes to be added do not have a search capability.
Additional codes need to be manually entered.
Presenter
Presentation Notes
Upon confirmation of procedure and site of service (or rendering provider) & prior to entering the clinical information collection, the provider will be prompted to indicated if there are additional procedures being requested for the same patient, being performed at the same site of service (or rendering provider) & same date of service. Additional codes to be added do not have a search capability. The applicable code has to be manually entered.
Verify Service Selection
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If the additional code cannot be added to the request you will see this message. The additional procedure code would require a separate authorization request/submission.
Presenter
Presentation Notes
If the additional code cannot be added to the request you will see this message. The additional procedure code would require a separate authorization request/submission. You may refer to the list of CPT codes that are allowed to be requested together in a single authorization. We’ll review this document later during the presentation. Refer to – CPT Codes That Can Be Requested on a Single Authorization
Verify Service Selection
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After entering all requested procedures, click “No” to proceed to the Clinical Certification.
Presenter
Presentation Notes
After entering all requested procedures, click NO to proceed to the Clinical Certification.
Clinical Certification
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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.
Presenter
Presentation Notes
Verify the information entered so far before proceeding into the clinical pathway section. You will not be able to edit the provider, patient or service information from the previous steps once selecting continue. After selecting Continue you would have to call eviCore to change any of the previously entered information.
Urgency Indicator
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If the case is standard select Yes.
If your request is urgent select No,Select an Urgency Indicator and Upload your patient’s relevant medical records
that support your request.
In order to submit an urgent request online, providers are required upload all
supporting clinical documentation, including medical records, during case
initiation. Important - If you choose to fax clinical
information, you must initiate the request via phone and provide the clinical
information over the phone or via fax (800) 540-2406.
You can upload up to FIVE documents in .doc, .docx, or .pdf format. Your case will only be considered Urgent if there is a
successful upload.
Note: Offices that are part of health systems may need to check with your internal IT resources to enable permission for upload capability.
Presenter
Presentation Notes
An Urgency Indicator has been added to the portal to allow submission of Urgent Auth Requests. If the case is standard select Yes. If your request is urgent select No, Select an Urgency Indicator and Upload your patient’s relevant medical records that support your request. In order to submit an urgent request online, providers are required upload all supporting clinical documentation, including medical records, during case initiation. You can upload up to FIVE documents in .doc, .docx, or .pdf format. Your case will only be considered Urgent if there is a successful upload. It is Important that if you choose to fax clinical information, you must initiate the request via phone and provide the clinical information over the phone or via fax (800) 540-2406. Please Note: that Offices which are part of a health system may need to check with your internal IT resources to enable permission for upload capability.
Clinical Certification
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Questions will populate based upon the information provided, such as procedure code and diagnosis code.
Fewer codes require
submission of clinical
information
Presenter
Presentation Notes
Now you're entering the clinical pathway. Answer the questions in the pathway related to your request. The clinical questions will populate based up the information previous provided and will be filtered dynamically based on how you answer each question.
Clinical Certification
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Do not utilize the “Finish Later” feature when initiating requests on NaviNet. This feature is not enabled. You may lose the clinical information which was
previously provided during clinical certification.
Presenter
Presentation Notes
Continue answering the questions in the pathway related to your request. Do not utilize the “Finish Later” feature when initiating requests on NaviNet. �The feature is not enabled and you may lose the clinical information which was already provided.
Clinical Certification
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Acknowledge the Clinical Certification statements, and hit “Submit Case.”
Presenter
Presentation Notes
Once the clinical pathway questions are complete you’ll have to check the Clinical Certification acknowledgement before selecting “submit case”.
Approval
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Once the clinical pathway questions are completed
and if the answers have met the clinical criteria, an
approval will be issued.
The Authorization Number will begin with an “A” followed by 9 digits.
Print the screen and store in the patient’s file.
Fewer codes require
submission of clinical
information
Presenter
Presentation Notes
Once the clinical pathway questions are completed and the answers have met the clinical criteria, an approval will be issued. There is a Print button so you store the approval in the patient’s file. The Authorization # will be an “A” following by 9 digits.
Medical Review
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If you don’t receive an immediate approval then you’ll be directed to this screen where there is the opportunity to provide additional clinical information. You will have the option
to either upload documentation, enter information into the text field, or contact us via phone. At this point, you know that your case is pended for medical review.
Presenter
Presentation Notes
If you don’t receive an immediate approval, you will be informed that your request is going on for further medical review. If additional information is needed to approve the case, you will have the ability to provide additional clinical documentation via upload of clinical documents, text box or telelphone. The first option will be the Text box. You may copy and paste information or free text. Once complete added any comments you’ll click submit to save the comments to the case.
Medical Review
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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 or fax.
Upload capability is a NEW feature
Presenter
Presentation Notes
The 2nd option is the ability to upload additional clinical documentation. You may attach up to 5 pdf and/or word files.
Medical Review
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Once the clinical pathway questions are complete and
additional clinical information is provided, the request is sent to Medical Review. A Case Number
will be issued.
The Case Number will be a 10 digit number beginning
with a “1”.
Print the screen and store in the patient’s file.
Presenter
Presentation Notes
If you case is sent to Medical Review you note the case status in the bottom left hand corner which indicates Status as “Your case has been sent to Medical Review”. You will also be issued an Case Number which will be a 10 digit number beginning with a “1”.
Auth Inquiry and Reports
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Auth Inquiry and Reports lets you check the real-time status and details of your authorization if you are the referred to or the referred from provider. You can search by Member ID, member
name or by Date of Service.
Presenter
Presentation Notes
Auth Inquiry and Reports lets you check the real-time status and details of your authorization if you are the referred to or the referred from provider. You can search by Member ID, member name or by Date of Service.
Auth Inquiry and Reports – Member ID search
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This is Auth Inquiry when searching by Member ID. eviCore provides an authorization starting with the letter A followed by 9 digits. NaviNet Authorization Inquiry displays EXT followed by 9
digits (for NaviNet submissions) or C followed by 9 digits (for phone/fax submissions).
Enhancement –Reduction in claim rejections for no authorization on
file
Presenter
Presentation Notes
This is Auth Inquiry when searching by Member ID. eviCore provides an authorization starting with the letter A followed by 9 digits. NaviNet Authorization Inquiry displays EXT followed by 9 digits (for NaviNet submissions) or C followed by 9 digits (for phone/fax submissions).
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This screen shows the Auth Inquiry search by Member name. Enter the members first name, last name and Date of birth. Select the member.
Auth Inquiry and Reports – Member Name Search
Presenter
Presentation Notes
This screen shows the Auth Inquiry search by Member name. Enter the members first name, last name and Date of birth. Select the member.
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After selecting the member, you will be taken to this screen where you will select the Billing Provider / Facility Name and search for the authorization by Date of Service.
Auth Inquiry and Reports – Member Name Search
Presenter
Presentation Notes
After selecting the member, you will be taken to this screen where you will select the Billing Provider / Facility Name and search for the authorization by Date of Service.
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This screen shows the Auth Inquiry Search by Date of Service
Auth Inquiry and Reports – Date of Service Search
Presenter
Presentation Notes
This screen shows the Auth Inquiry Search by Date of Service
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Although you cannot initiate requests directly on eviCore.com, the Authorization Lookup function is enabled on the CareCore National Portal. You may search by Member Information or Auth/Case Number. For new users, to search authorization status, you can create a new login by going to www.evicore.com,
click ‘Providers’ at the top of the webpage and when prompted to enter a User ID and Password, under the Login button click ‘Register’ and complete the user registration form.
eviCore.com – Authorization Lookup Function
Presenter
Presentation Notes
Although you cannot initiate requests directly on eviCore.com, the Authorization Lookup function is enabled on the CareCore National Portal. You may search by Member Information or Auth/Case Number. Please make sure you are utilzing the CCN portal and not the MedSolutions portal to access the authorization lookup function for Highmark requests. For new users, to search authorization status, you can create a new login by going to www.evicore.com, click ‘Providers’ at the top of the webpage and when prompted to enter a User ID and Password, under the Login button click ‘Register’ and complete the user registration form.
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Provider Resources
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Presentation Notes
Next we’ll review so
Highmark Provider Resource Center
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To access Advanced Imaging & Cardiology Services Program educational materials on Highmark’s Provider Resource center go to www.highmark.com. Click Providers and the applicable “Plan Name” under For Providers.
You can also get to the Provider Resource Center in NaviNet by selecting Resource Center on Highmark’s Plan Central Page.
Resource Center in NaviNet
Highmark Provider Resource Center
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Then click + next to Care Management Programs and then select Advanced Imaging and Cardiology Services Program. Provider Educational Materials/Communications are posted on this site.
Presenter
Presentation Notes
Refer to - Allowable Billed Groupings
Radiology/Cardiology Online Resources
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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. This information is also accessible on the eviCore/Highmark Provider Resource Page - https://www.evicore.com/healthplan/highmark
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 Cardiology or Radiology from the dropdown menu.
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/insights .
Provider Resources: Prior Authorization Call Center
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7:00 AM - 7:00 PM (EST): (888) 564-5492*
• Obtain prior authorization 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 check
eviCore fax* number: (800) 540-2406
*NaviNet remains the preferred initiation method
Client ProviderOperations
Pre-Certification Call Center
Web-Based Services
Documents
Provider Resources: Web-Based Services
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www.evicore.com
To speak with a Web Specialist*, call (800) 646-0418 (Option #2) or email [email protected].
Highmark 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
