Gateway Health and Gateway Medicare Assured℠

Medical Specialty Solutions

Musculoskeletal (MSK) Management & Interventional Pain Management(IPM) Programs

SEPTEMBER 2019

Presented by:

Magellan Healthcare Training Program

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Our Program

1. Authorization Process

2. Other Program Components

3. Provider Tools and Contact Information

RadMD Demonstration

Questions and Answers

Magellan Healthcare Program Agenda

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A Unique Vision of Care

>20% clinical disapproval

rates

As the nation’s leading specialty health care management company, we deliver comprehensive and innovative solutions to improve quality outcomes and

optimize cost of care.

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National Imaging Associates, Inc. (NIA) is an affiliate of Magellan Health Services

Magellan Facts

Magellan Facts

• Providing Client Solutions since 1995

• Magellan Acquisition (2006)

• Headquartered in Scottsdale, AZ

• Business supported by two National Call Operational Centers

Industry Presence

• 77 Health Plan Clients serving 27.37 million National Lives

• 15.01 million Commercial

• 1.90 million Medicare

• 10.47 million Medicaid

• 42 states

Clinical Leadership

• Strong panel of internal Clinical leaders – client consultation; clinical framework

• Supplemented by broad panel of external clinical experts as consultants (for guidelines)

Product Portfolio

• Advanced Diagnostic Imaging

• Cardiac Solutions

• Radiation Oncology

• Musculoskeletal Management (Surgery/IPM)

• Physical Medicine (Chiropractic Care, Speech Therapy, Physical and Occupational Therapies)

• Provider Profiling and Practice Management Analysis

URAC Accreditation & NCQA Certified

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Magellan Healthcare Prior Authorization Program

Outpatient/Office Interventional Pain Management (IPM)

Spine Procedures

Spinal Epidural Injections Paravertebral Facet Joint Injections or Blocks Paravertebral Facet Joint Denervation (Radiofrequency

Neurolysis) Sacroiliac Joint Injections

Excluded from Program-Interventional Pain Management (IPM) Procedures Performed in the Following Settings:

Hospital Inpatient Observation Room Emergency Room/Urgent Care Facility

Procedures Performed on or after October 1, 2019 Require Prior Authorization Magellan Healthcare’s Call Center & RadMD will open September 20, 2019

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Lumbar Microdiscectomy Lumbar Decompression (Laminotomy, Laminectomy,

Facetectomy & Foraminotomy) Lumbar Spine Fusion (Arthrodesis) With or Without

Decompression – Single & Multiple Levels Cervical Anterior Decompression with Fusion –Single &

Multiple Levels Cervical Posterior Decompression with Fusion –Single &

Multiple Levels Cervical Posterior Decompression (without fusion) Cervical Artificial Disc Replacement Cervical Anterior Decompression (without fusion)

Excluded from Program-Surgeries Performed in the Following Settings:

Emergency Surgery – admitted via the Emergency Room

Inpatient and Outpatient Lumbar & Cervical Spine Surgery

Please note that CPT Codes 22800-22819 used for reconstructive spinal deformity surgery and the associated instrumentation do not require Magellan Healthcare/Gateway Health prior authorization. Magellan Healthcare will monitor the use of these CPT codes, but prior authorization is not currently required. As long as the deformity surgery does not include CPT codes on Magellan Healthcare/Gateway Health utilization review matrix/prior authorization list, the claim for the case will process accordingly.

Magellan Healthcare Prior Authorization Program

Inpatient and Outpatient

Hip, Knee and Shoulder Surgery

Inpatient and Outpatient Hip Surgery :

Revision/Conversion Hip Arthroplasty Total Hip Arthroplasty/Resurfacing Femoroacetabular Impingement (FAI) Hip Surgery

(includes CAM/pincher & labral repair) Hip Surgery – Other (includes synovectomy, loose body

removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)

Inpatient and Outpatient Knee Surgery :

Revision Knee Arthroplasty Total Knee Arthroplasty (TKA) Partial-Unicompartmental Knee Arthroplasty (UKA) Knee Manipulation under Anesthesia (MUA) Knee Ligament Reconstruction/Repair Knee Meniscectomy/Meniscal Repair/Meniscal

Transplant Knee Surgery – Other (includes synovectomy, loose body

removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)

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Inpatient and Outpatient Shoulder Surgery Revision Shoulder Arthroplasty Total/Reverse Shoulder Arthroplasty or Resurfacing Partial Shoulder Arthroplasty/Hemiarthroplasty Shoulder Rotator Cuff Repair Shoulder Labral Repair Frozen Shoulder Repair/Adhesive Capsulitis Shoulder Surgery – Other (includes debridement,

manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

Excluded from Program- Hip, Knee & Shoulder Surgeries Performed in the Following Settings:

Emergency Surgery – admitted via the Emergency Room

• Magellan Healthcare will use the Gateway Health and Gateway Health Medicare Assured network of Pain Management Physicians, Surgeons, Hospitals, Surgery Centers, and In-Office Providers as it’s preferred providers for delivering Outpatient Interventional Spine Pain Management Services and select Inpatient and Outpatient Surgeries to Gateway Health members throughout Pennsylvania.

Using Gateway Health’s Network

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List of CPT Procedure Codes Requiring Prior Authorization

• CPT codes and their allowable billable groupings

• Defer to Gateway Health plan policies for procedures not on claims/utilization review matrix

• Located on RadMD.com

• Review claims/utilization review matrix to determine CPT codes managed by Magellan Healthcare

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Responsibility for Authorization

Ordering Providers

Responsible for obtaining prior authorization

Facility/Place of Service

Ensuring that prior authorization has been obtained prior to providing service

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Prior Authorization Process Overview

Ordering Physician

Or Online Through RadMD

www.RadMD.com

Algorithm

Service AuthorizedRendering Provider

Performs ServiceClaim

Information evaluated via algorithm and medical records

Submit Requests by Phone

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Patient and Clinical Information Required Information for Authorization

GENERAL

Includes things like ordering physician information, member information, place of service, requested procedure, etc.

CLINICAL INFORMATION

• Clinical Diagnosis

• Physical exam findings and patient symptoms (including findings applicable to the requested procedure)

• Date of onset of pain or exacerbation. Duration of patient’s symptoms.

• Conservative treatment modalities completed, duration, and results (e.g., physical therapy , chiropractic or osteopathic manipulation, hot pads, massage, ice packs and/or medication)

• Date and results of prior interventional pain management procedures, where applicable.

• Diagnostic imaging results, where applicable.

• Preliminary procedures already completed (e.g., lab work, scoped procedures, referrals to specialist, specialist evaluation)

SPECIAL INFORMATION

•For spinal surgeries, only one authorization request per surgery. For example, a Lumbar fusion authorization includes decompression, instrumentation, etc.

•An inpatient hospital stay must be prior authorized through Gateway Health for an approved surgery.

•Every interventional pain management procedure performed requires a prior authorization; Magellan Healthcare does not pre-approve a series of epidural injections.

•Date of Service is required.

•Bilateral hip or knee surgeries require two separate authorizations.

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Magellan Healthcare Clinical Foundation & Review

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Peer-to-Peer Discussion

Clinical Review by Magellan Healthcare’s Specialty Experts

Fax/Upload Clinical Information (upon request)

Clinical Algorithms collect pertinent information

Clinical Guidelines Are the Foundation

Clinical guidelines and algorithms were developed by practicing specialty physicians, literature reviews, and evidence base. Guidelines are reviewed and mutually approved by Gateway Health and Magellan Healthcare’s Chief Medical Officers and Clinical Specialty Experts.

Validation of clinical criteria within the patient’s medical record is required before an approval can be made.

Magellan Healthcare reviews key clinical information to ensure that Gateway Health members are receiving appropriate care prior to more invasive procedures being performed.

Magellan Healthcare has a specialized clinical team focused on musculoskeletal care. Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines.

Medicaid re-review is allowed for 14 calendar days from the date of denial by P2P only. You may follow appeal process through Gateway Health defined in the notice of the denial provide to you.

Medicare re-open is NOT allowed.

No change in current appeals process.

Our goal – ensure that Gateway Health members are receiving appropriate musculoskeletal care.

Clinical Guidelines available on www.RadMD.com

Magellan Healthcare to Physician: Request for Clinical Information

• A fax is sent to the provider detailing what clinical information that is needed, along with a Fax Coversheet

• We stress the need to provide the clinical information as quickly as possible so we can make a determination

• Determination timeframe begins after receipt of clinical information

• Failure to receive requested clinical information may result in non certification

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Location of Fax Coversheets:

Can be printed from www.RadMD.com

Call

Medicare 1-800-424-1728

Medicaid 1-800-424-4890

Use the case specific fax coversheets when faxing clinical information to Magellan Healthcare

Records may be submitted:

Upload to www.RadMD.com

Fax using that Magellan Healthcare coversheet

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Submitting Additional Clinical Information

Clinical Specialty Team: Focused on MSK

Clinical Specialty Team

MSK Surgery Reviews

Surgery concierge team will

proactively outreach for

additional information,

reconsiderations and to schedule

peer-to-peer session.

Nurses will assemble surgery

cases and reach out for clinical

information as needed prior to

sending to surgeon reviewers.

Only orthopedic surgeons or

neurosurgeons conduct clinical

reviews and peer-to-peer discussion

on surgery requests.

Specialized Clinical Team

IPM Reviews

Initial clinical review performed by Magellan Healthcare neurology

team nurses

The clinical specialties supporting our IPM

program include anesthesiology,

orthopedic spine surgery, neurology, neurosurgery,

and pain specialists

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Notification of Determination

• Authorizations

Validity Period - Authorizations are valid for:

• IPM

• 60 days from Date of Service / Request

• Surgical

• Inpatient – 60 days from Date of Service / Request*

• Outpatient- SDC/Ambulatory –60 days from Date of Service / Request

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• Denials

• You may ask Magellan Healthcare for a reconsideration of our decision with additional information. You may also follow the appeal process through Gateway Health defined in the notice of denial provided to you.

Authorization Notification Denial Notification

*The date of service that is selected at the time of the prior authorization request, will be used to determine the validity period. If the DOS changes please contact Magellan Healthcare to update.

Magellan Healthcare Urgent/Expedited Authorization Process

If an urgent clinical situation exists (outside of a hospital emergency room), please call Magellan Healthcare immediately. The number to call to obtain a prior authorization is:

• Medicaid: 1-800-424-4890 • Medicare: 1-800-424-1728

Urgent/Expedited Authorization Process

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Summary Interventional Pain Management (IPM) Points

• Injections in all regions of spine are managed

• Date of Service is required for all requests

• Each IPM procedure must be prior authorized

• No series of epidural injections

• Specialty Nurses and Physicians will review IPM requests

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Summary Musculoskeletal Surgery Points

Lumbar/Cervical Spine Surgery• Inpatient and outpatient non-emergent

surgeries

• Spine Surgery is focused on lumbar and/or cervical spine surgeries

• For spinal surgeries, only one authorization request per surgery. For example, a Lumbar fusion authorization includes decompression, instrumentation, etc.

• CPT Codes 22800-22819 used for reconstructive spinal deformity surgery and the associated instrumentation do not require prior authorization. Magellan Healthcare will monitor the use of these CPT codes. As long as the deformity surgery does not include CPT codes on Magellan Healthcare/Gateway Health Utilization Review Matrix and Prior Authorization list, the claim for the case will process accordingly

Hip, Knee and Shoulder Surgery • Bilateral hip or knee surgeries require two

separate authorizations

• Surgeries addressing the following are not included in the musculoskeletal management program: trauma, amputation, fracture, active infection, pediatric conditions, congenital malformation, dysplasia (hip), palsy/plegia, osteochondritis dissecans (knee), osteotomy (knee), tumor, cyst, cancer, arthrodesis, girdle resection (hip), denervation (hip), joint dislocation, hemiarthroplasty (hip), & foreign body

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Summary Musculoskeletal Surgery Points Continued…

For all surgeries…

• Specialized Orthopedic Surgeons or Neurosurgeons will review surgery requests.

• Any Gateway Health Medicare Assured or Medicaid prior authorization requirements for the facility or hospital admission must be obtained separately and only initiated after the surgery has met Magellan Healthcare’s medical necessity criteria.

• Authorizations are valid for 60 days from the date of service or if no date of service is available, then from date of request. Magellan Healthcare must be notified of any changes to the date of service.

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Provider Tools

Toll free authorization and information number:

• 1-800-424-4890 (Medicaid)

• 1-800-424-1728 (Medicare – PA)

Available 8:00 a.m. – 8:00 p.m. EST

• Interactive Voice Response (IVR) System for authorization tracking

RadMD Website, www.RadMD.com – Available 24/7 (except during maintenance)

• Request Authorization

• View Authorization Status

• Upload Additional Clinical Information

• View Clinical Guidelines

• View Frequently Asked Questions (FAQs)

• View Other Educational Documents

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Magellan Healthcare's Website www.RadMD.com

RadMD Functionality varies by user:

• Rendering Provider – Views approved authorizations for their facility.

• Ordering Provider’s Office – View and submit requests for authorization.

Online Tools Accessed through www.RadMD.com:

• Magellan Healthcare’s Clinical Guidelines

• Frequently Asked Questions

• Quick Reference Guides

• RadMD Quick Start Guide

• Claims/Utilization Matrices

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Ordering Provider: Getting Started on RadMD.com(MSK)

STEPS:

1. Click the “New User” button on the right side of the home page.

2. Select “Physician’s office that orders procedures”

3. Fill out the application and click the “Submit” button.

− You must include your e-mail address in order for our Webmaster to respond to you with your Magellan Healthcare-approved user name and password.

NOTE: On subsequent visits to the site, click the “Sign In” button to proceed.

1Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations.

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3

Offices that will be both ordering and rendering should request ordering provider access, this will allow your office to request authorizations on RadMD and see the status of those authorization requests.

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Rendering Provider: Getting Started on RadMD.com(MSK)

STEPS:

1. Click the “New User” button on the right side of the home page.

2. Select “Facility/office where procedures are performed”

3. Fill out the application and click the “Submit” button.

− You must include your e-mail address in order for our Webmaster to respond to you with your Magellan Healthcare-approved user name and password.

NOTE: On subsequent visits to the site, click the “Sign In” button to proceed.

IMPORTANT

• Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations.

• Designate an “Administrator” for the facility who manages the access for the entire facility.

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If you have multiple staff members entering authorizations and you want each person to be able to see all approved authorizations, they will need to register for a rendering username and password. The administrator will have the ability to approve rendering access for each employee. This will allow users to see all approved authorizations under your

organization.

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When to Contact Magellan Healthcare:

Providers: To initiate a request for an authorization: please contact Magellan Healthcare via website,

www.RadMD.com or via toll-free number 1-800-424-4890 (Medicaid) 1-800-424-1728 (Medicare – PA)

To check the status of an authorization: please contact Magellan Healthcare via website, www.RadMD.com or Interactive Voice Response (IVR) System 1-800-424-4890 (Medicaid) 1-800-424-1728 (Medicare – PA)

For assistance or questions directed to Magellan Healthcare: call the Provider Service Line at 1-800-327-0641.

For assistance or technical support for RadMD: please contact RadMD Help Desk via e-mail RadMDSupport@magellanhealth.com or 877-80-RadMD (877-807-2363).

For any provider education requests or questions specific to Magellan Healthcare and the Physical Medicine, and MSK Program, please contact: Justin Clifford PT, DPT Lori Fink

Sr. Provider Relations Manager Provider Relations Managerjclifford@magellanhealth.com lafink@magellanhealth.com1-800-450-7281, ext. 55721 1-800-450-7281, ext. 75335

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RadMD Demonstration

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Confidentiality Statement

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The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Gateway Health and Gateway Health Medicare Assured members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Gateway Health and Gateway Health Medicare Assured and Magellan Healthcare, Inc.

Questions?