Download CareCore NJAAHAM Final 03282013

CareCore National Overview
March 28, 2013
CareCore National Overview
CareCore National utilizes research based clinical expertise to improve
quality and reduce inappropriate utilization.
 Nation’s largest Specialty Benefit Management company
 Utilizing Innovative Data and Information Technology
 Client Driven and Clinically Focused
 Certified to provide Utilization Management (UM) services in all 50
states
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CareCore National Infrastructure
 Over 17 years of managing evidence-based outpatient health care services
 First to market with Specialty Benefit Management programs
Experience
 Clients include Commercial, Medicare, Medicaid and FEP members
 Manage over 75 million lives, 35 million radiology lives
Clinical
Expertise
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Comprehensive appropriateness criteria based on evidence-based
guidelines and peer reviewed literature
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Advisory panels of both academic and private physicians
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Unparalleled clinical resources
– Team of 55+ full-time board-certified physicians representing all major specialties
– All clinical questions conducted by nurses
Infrastructure
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Fully integrated operational centers in:
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South Carolina - Colorado - Remote Employees in over a dozen states
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All utilizing next-in-queue technology to ensure operational continuity
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45,000 Reviews Daily. Supported by a dedicated, in-house IT team
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Over 1,200 employees nationwide
© 2012 CareCore National, LLC. All Rights Reserved.
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CareCore National Clients
© 2013 CareCore National, LLC. All Rights Reserved. This presentation contains
CONFIDENTIAL and PROPRIETARY information.
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CareCore National IT Infrastructure
Network & Telephony
System Volumes
Over 40,000 calls daily. Exceeding 7M
clinical reviews annually. Adjudicating over
6M imaging claims annually.
Network & Telephony
 Multiple full function data centers
 Redundant (full load) data center
connectivity
 Geographically distributed redundant
telephonic core switching including
hardware and trunking capacity
Applications & Data Storage
 Core application processing capability carried out via
dual ‘on line’ data centers.
 100% of critical platforms are replicated in real time.
 Utility based Compute, Storage and Network
platforms (private cloud deployed)
 ATMOS policy based storage for unstructured data
components.
Call Center Operations
 All facilities, including remote agents, act as a single call
center utilizing next-in-queue technology protecting against
regional effects to operations
© 2012 CareCore National, LLC. All Rights Reserved.
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Web-Based Solutions and Access
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www.carecorenational.com
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Secure, single sign-on
capability
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Real-time online
authorizations
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24/7 online capability to
initiate authorizations,
verify real-time
authorization status, and
eligibility look up
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Online guidelines, quick
reference guides, and
program documents

Health Plan link to reporting
mechanisms for real-time
data regarding employer
group and/or provider
activity
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Physicians can review the CareCore evidence-based guidelines at
any time at www.carecorenational.com.
© 2013 CareCore National, LLC. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.
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PROGRAM OBJECTIVES
PROGRAM OVERVIEWS
The
Importance of Evidence-Based Care
NJ HEALTH PLAN PROGRAM SUMMARIES
© 2012 CareCore National, LLC. All Rights Reserved.
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UM Program Objectives
1. Ensure Quality of Care
2. Maximize Member Benefit Options
3. Ensure Appropriate Use of Services
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Clinical Review Workflow
Advanced Imaging ▪ Cardiac Imaging ▪ Radiation Therapy
▪ Musculoskeletal (Pain Mgt) ▪ Oncology ▪ Sleep Studies
Meets Clinical Criteria APPROVED
Approved
Medical Service
Licensed Nurse
Review
Physician Review
Peer-to-Peer Available
© 2013 CareCore National, LLC. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.
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Radiology Program Components
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Advanced Imaging Services
CAT Scan
MRI/MRA
PET
Nuclear Medicine
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Outpatient Services
Approval valid 45 days
TAT Standard 2 BD upon receipt of
completed clinical documentation
Urgent up to 3 hours
Radiology Benefit Management Tools
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Prior authorization/MND
Scheduling
Education
Comprehensive reporting
Peer to Peer Consultation
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Radiology Member Scheduling
CareCore National offers a “Concierge Service” to assist health plan members in scheduling their
approved advanced imaging procedure to the imaging facility which best meets the member’s needs.
Member Benefits
Member education of the available facilities based on
highest quality, convenient location, continuity of care
and cost-effectiveness
A live warm hand off to the facility to assist in
scheduling an approved procedure at convenient time
and location of the member’s preference
Over 98% member satisfaction
Members schedule appointments for Advanced
Imaging Services:
CT/CTA
MRI/MRA
PET
PET/CT
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Radiology Scheduling Process Overview
 Call CareCore National or go to www.carecorenational.com to obtain a prior
authorization or medical necessity determination (PA/MND)
 At the end of the review the provider is given a case number
 Upon approval CCN will contact the member by telephone and schedule the
procedure at a participating facility
 Members can contact CCN directly for scheduling assistance (Telephone number is
health plan specific)
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Self-Referral & Payment Policies
“Limiting the scope of imaging
procedures that a physician, site or
specialty will be authorized for
payment when self-referred.”
Self-Referral Policy
• Essential to appropriately diagnose patients
• Appropriate to their training
Payment Policies
• Coding & Bundling Rules
• Disallows up coding and limits technical fees
• CPT Code DRG Specific Claim logic
© 2012 CareCore National, LLC, All Rights Reserved
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Cardiology Management
Cardiology Program Components
Diagnostic Studies
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Nuclear stress test
Echo stress test
Cardiac PET
Cardiac MRI
Coronary CT angiography (CCTA)
Diagnostic left heart catheterization
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Outpatient Services
Approval valid 45 days
TAT Standard 2 BD upon receipt of
completed clinical documentation
Urgent up to 3 hours
Cardiac Benefit Management Tools
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Prior authorization/MND
Comprehensive reporting
Education
Quality equipment and accreditation requirements
Peer to Peer Consultation
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Online Cardiology Prior Authorization Program
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Online Prior Authorization Submission & Processing
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Patient Prior Authorization History
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Patient & Site Eligibility Verification
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Authorization Status Look-up
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Case Status Availability
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Radiation Therapy Program Components
Cancer Types:
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Bone Metastases, Brain metastases, Breast Cancer,
Prostate Adenocarcinoma, Lung Cancer
(SCLC/NSCLC), Cervical Cancer, Pancreatic
Cancer, Rectal Adenocarcinoma, Head/Neck
Carcinoma, Endometrial Cancer, Gastric Cancer,
Primary CNS Lymphoma, Primary CNS Neoplasms
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Outpatient Services
TAT Standard 2 BD upon receipt of completed
clinical documentation
Urgent up to 3 hours
Other Cancer Diagnoses that require Radiation Treatment
RT Benefit Management Tools
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Medical Necessity Determination
Education
Comprehensive reporting
Peer to Peer Consultation
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Radiation Therapy
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CareCore National’s extensive evidence-based criteria are written based on national
Advisory Committee review of evidence based literature in alignment with existing American
College of Radiology (ACR) and American Society for Therapeutic Radiology and Oncology
(ASTRO) guidelines
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The criteria is listed on the CareCore website:
1. Go to www.carecorenational.com
2. Click on CareCore Solutions
3. Click on Radiation Therapy, Radiation Therapy Tools & Criteria
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Radiation Therapy
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To initiate a Radiation Therapy request, the physician providing the radiation treatment plan will be
required to complete all questions on the specific worksheet.
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The Worksheets are located on the CareCore National Website.
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The requests are to be submitted by WEB or by Telephone only
 No requests may be faxed
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A medical necessity determination number will be issued when medical necessity is finalized
including the description of the approved treatment plan including technique, treatment sessions
and gantry angles
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Radiation Therapy
A finalized medical necessity determination will result in one of three decisions:
1.
FULL approval - the treatment plan requested is approved
2.
FULL denial - the treatment plan requested in non-certified
3.
PARTIAL approval - the treatment plan requested including treatment sessions and gantry
angles is partially approved, allowing only a portion of the requested quantities and noncertifying the remainder
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Radiation Therapy
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The provider and member are notified in writing of the decision
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Authorization status can also be verified on the CareCore website
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CareCore National Radiation Oncologists are available to speak with a referring or rendering
physician at any time during the course of treatment
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If a modification is required for an authorized treatment plan, the ordering provider’s office
should contact CareCore National to request an update to an existing treatment plan
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Oncology Management
Oncology Program Components
Oncology & Injectable Drug Management
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Chemotherapeutic Agents
Adjunctive Therapies
Supportive Therapies
ESA Agents
Anti-Angiogenesis Drugs
TNF Inhibitors
IVIG Products
Other Biotherapeutics
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Outpatient Services
Approval valid 56 days
TAT Standard 2 BD upon receipt of
completed clinical documentation
Urgent up to 3 hours
Oncology Benefit Management Tools
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Medical Necessity Determination
Education
Comprehensive reporting
Peer to Peer Consultation
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Musculoskeletal Management
Program Components
 Comprehensive multidisciplinary treatment
plans that include conservative care
 Proven and unproven interventional techniques
 Imaging guidance of procedures
 The use of approved oral and injectable
medications
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Outpatient Services
TAT Standard 2 BD upon receipt of
completed clinical documentation
Urgent up to 3 hours
Benefit Management Tools
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Medical Necessity Determination
Education
Comprehensive reporting
Peer to Peer Consultation
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Sleep Management
Program Components
 Sleep Diagnostics
 Sleep Therapy Devices and Supplies
 PAP Therapy Compliance
Benefit Management Tools
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Prior Authorization for Sleep Diagnostics & Therapy
Facility and Home Testing management
Compliance Monitoring & Reporting
Network Management & Development
Sleep Medical Management Policies
Peer to Peer Consultation
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Oxford Program Overview
In New Jersey
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Post Service Medical Necessity Review
Effective 1/1/2013
• New Jersey Small group and Individual plans
• New Jersey Municipality plans
• New Jersey School Board plans
In New York
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Radiology Management Program
Effective 2/1/2002
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Member Scheduling Program
Effective 4/1/2006
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Cardiology Management Program
MPI -Effective 9/1/2006
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Radiation Therapy Program
Effective 12/1/09
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Aetna Northern New Jersey Program Overview
Aetna HMO Plans Covered:
Commercial, ASO, Medicare
Counties Covered: Bergen, Essex, Hudson, Hunterdon,
Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset,
Sussex, Union, Warren
Aetna PPO Plans Covered:
Commercial, Medicare
Counties Covered: Bergen, Essex, Hudson, Hunterdon,
Middlesex, Monmouth, Morris, Ocean, Passaic,
Somerset, Sussex, Union, Warren
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Radiology Management Program
Effective 8/1/2002
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Radiology Management Program
Effective 5/1/2007
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Member Scheduling Program
Effective 9/1/2005
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Claims Payment (Commercial, ASO, Medicare)
Effective 9/1/2006
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Cardiology Management Program
MPI -Effective 9/1/2006
Stress Echo, Left Heart Cath – Effective 8/1/2009
Right Heart Cath – Effective 5/15/2010
Cardiac Implantables, Cardiac MRI, Cardiac PET, Cardiac CT
CCTA- Effective 6/1/2012
Member Scheduling Program (Home Depot
members only)
Effective 1/1/2010
Member Scheduling Program (Aetna, Inc.
PPO employees )
Effective 5/1/2010
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Sleep Management Program
Effective 11/1/2009
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Radiation Therapy Program
Effective 6/1/2010
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Cardiology Program:
Effective 5/1/2010
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Horizon Blue Cross Blue Shield NJ Program Overview
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Radiology (Effective Date: 1/1/2005)
 Horizon Radiology Program Prior Authorization/Medical Necessity Determination
 Member Scheduling
 Payment Policies
 Privileging
 Comprehensive Reporting
 Quality Assurance/Management
 Payment Policies
 Peer to Peer Consults
 Outpatient Services
 Approval valid 45 days
 TAT Standard 2 BD upon receipt of completed clinical documentation
 Urgent up to 3 hours
Cardiology (Effective Date: 3/1/2008)
 Horizon Cardiology Management Prior Authorization/Medical Necessity Determination
 Echocardiogram (Effective 7/1/2009)
 Credentialing & Privileging (Effective 11/30/2009)
 Transthoracic and Stress Echocardiogram ( Effective 11/30/2009)
 Education
 Privileging
 Comprehensive Reporting
 Quality Assurance/Management
 Outpatient Services
 Approval valid 45 days
 TAT Standard 2 BD upon receipt of completed clinical documentation
 Urgent up to 3 hours
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Horizon Blue Cross Blue Shield NJ Program
Overview Continued
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Oncology (Effective Date: 4/1/2007)
 Oncology UM Program -Medical Necessity Determination
 Epoge/Procrit
 Aranesp
 Education
 Comprehensive Reporting
 Peer to Peer Consultation
 Outpatient Services
 Approval valid 56 days
 TAT Standard 2 BD upon receipt of completed clinical documentation
 Urgent up to 3 hours
Radiation Therapy (Effective Date: 3/1/2009)
 Radiation Therapy Utilization Management Program -Medical Necessity Determination
 Education
 Comprehensive Reporting
 Peer to Peer Consultation
 Outpatient Services
 TAT Standard 2 BD upon receipt of completed clinical documentation
 Urgent up to 3 hours
Musculoskeletal Utilization Management ( Effective Date: 4/26/2010)
 MSM Utilization Management -Program Medical Necessity Determination
 Education
 Comprehensive Reporting
 Peer to Peer Consultation
 Outpatient Services
 Approval valid 45 days
 TAT Standard 2 BD upon receipt of completed clinical documentation
 Urgent up to 3 hours
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Questions
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