Download HMSA Medical Specialty Solutions Frequently Asked

NIA Magellan1 Frequently Asked Questions (FAQ’s)
For Hawai‘i Medical Service Association (HMSA) Providers
Question
GENERAL
Why is HMSA
implementing a
Medical Specialty
Solutions Program?
Answer
We are implementing a Medical Specialty Solutions Program
to improve quality and manage the utilization of the following
non-emergent procedures.
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CT/CTA
MRI/MRA
PET Scan
CCTA
Myocardial Perfusion Imaging (MPI)
Stress Echocardiography(Effective December 1, 2015)
Implantable Cardiac Devices (Effective December1, 2015)
Cardiac Catheterization (Effective December1, 2015)
Musculoskeletal (Effective January 1, 2014)
Why did HMSA
An affiliate of Magellan Health Services, NIA Magellan was
select NIA
selected to partner with HMSA because of their clinically
Magellan to
driven program designed to effectively manage the quality
manage its Medical and patient safety while ensuring appropriate utilization of
Specialty Solutions resources for HMSA membership.
Program?
Which HMSA
NIA Magellan will be managing all HMSA membership using
members will be
HMSA contractual providers.
covered under this
relationship and
what networks will
be used?
PRECERTIFICATION
The program began on April 16, 2007. HMSA is expanding
What is the
their cardiac precertification program to include Stress
Implementation
Date for the Medical Echocardiography, Implantable Cardiac Devices and Cardiac
Catheterization effective December 1, 2015.
Specialty Solutions
Program?
1________________________________
1
NIA Magellan refers to National Imaging Associates, Inc.
1—HMSA – Frequently Asked Questions
What Medical
Specialty Solutions
Services require
providers to obtain a
precertification?
Is precertification
required if the
provider has a
waiver?
Can the rendering
providers use
RadMD.com to
verify if the study
requires prior
authorization?
Is precertification
necessary for
sedation with an
MRI?
Is an NIA Magellan
precertification
number needed for a
CT-guided biopsy?
Can a chiropractor
order images?
Are routine Imaging
services a part of
this program?
The following non- emergent, Medical Specialty Solutions
services require precertification through NIA Magellan :
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CT/CTA
MRI/MRA
PET Scan
CCTA
Myocardial Perfusion Imaging (MPI)
Stress Echocardiography(Effective December1, 2015)
Implantable Cardiac Devices (Effective December1, 2015)
Cardiac Catheterization (Effective December1, 2015)
Musculoskeletal (Effective January 1, 2014)
Emergency room, observation and inpatient procedures do
not require precertification from NIA Magellan. If an
urgent/emergent clinical situation exists outside of a hospital
emergency room, please contact NIA Magellan immediately
with the appropriate clinical information for an expedited
review (excluding spine surgery).
Please note that all current waivers from prior authorization
will end on November 30, 2015. Those providers under the
current waiver will require prior authorization for all of the
services above effective December 1, 2015.
Today rendering providers have the ability to check to see if
the provider ordering the study they will perform requires
prior authorization. This will be turned off on December1,
2015 and all providers will be required to prior authorize
requests.
No, precertification is not required for sedation when
performed with an MRI.
No, precertification is not required for this procedure.
Chiropractors cannot order images for Medicare or Medicare
Advantage members.
No
2—HMSA – Frequently Asked Questions
Are inpatient
Diagnostic Imaging
(MR, CT/CCTA,
PET) procedures
included in this
program?
Is precertification
required for Medical
Specialty Solutions
Services performed
in the emergency
room?
How does the
ordering provider
obtain a
precertification from
NIA Magellan for an
outpatient
Diagnostic Imaging
service?
What information is
required in order to
receive
precertification?
No.
No. Medical Specialty Solutions Services performed in the
emergency room are not included in this program and do not
require precertification through NIA Magellan.
Providers will be able to request precertification via the
internet (www.RadMD.com) or by calling NIA Magellan at 1866-306-9729.
To expedite the precertification process, please refer to the
specific required documentation for each Medical Specialty
Solution. Have the appropriate information ready before
logging into NIA Magellan’s Website or calling NIA
Magellan’s Call Center (*Information is required.)
 Name and office phone number of ordering physician*
 Member name and ID number*
 Requested examination*
 Name of provider office or facility where the service will
be performed*
 Anticipated date of service
 Details justifying examination.*
 Symptoms and their duration
 Physical exam findings
 Conservative treatment patient has already
completed (e.g., physical therapy, chiropractic or
osteopathic manipulation, hot pads, massage, ice
packs, medications)
 Preliminary procedures already completed (e.g., xrays, CTs, lab work, ultrasound, scoped procedures,
referrals to specialist, specialist evaluation)
 Reason the study is being requested (e.g., further
evaluation, rule out a disorder)
3—HMSA – Frequently Asked Questions
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Please be prepared to provide the following information, if
requested
o
o
o
o
o
Can a provider
request more than
one service at a time
for a member?
Clinical notes
X-ray reports
Previous related test results
Specialist reports/evaluation
Ultrasound reports
*To assist in collecting information for the
precertification process, you may access the specific
medical specialty and disease specific
(precertification or treatment plan checklists) on
www.RadMD.com.
NIA Magellan can handle multiple precertification requests
per contact. Separate precertification numbers are issued by
NIA Magellan for each service that is precertified.
What kind of
response time can
ordering providers
expect for
precertification?
A determination will be made within 2 calendar days after
receipt of clinical information.
What does the NIA
Magellan
precertification
number look like?
The NIA Magellan precertification number consists of 10
alpha-numeric characters. In some cases, the ordering
provider may receive an NIA Magellan tracking number (not
the same as a precertification number) if the provider’s
precertification request is not approved at the time of initial
contact. Providers can use either number to track the status
of their request online or through an Interactive Voice
Response (IVR) telephone system.
If requesting
precertification
through RADMD
and the request
pends, what
happens next?
Can RadMD be used
to request an
expedited
precertification
request?
You will receive a tracking number and NIA Magellan will
contact you to complete the process.
No, expedited requests will need to be called into NIA
Magellan’s Call Center for processing.
4—HMSA – Frequently Asked Questions
What happens if a
patient is
precertified for a
service and the
provider feels an
additional study is
needed?
Can the rendering
facility obtain
precertification in
the event of an
urgent service?
If the provider feels that, in addition to the service already
precertified, an additional service is needed, please contact
NIA Magellan immediately with the appropriate clinical
information for an expedited review. The number to call to
obtain precertification is 1-866-306-9729.
If a provider obtains
a precertification
number does that
guarantee payment?
A precertification number is not a guarantee of payment.
Precertification’s are based on medical necessity and are
contingent upon eligibility and benefits. Benefits may be
subject to limitations and/or qualifications and will be
determined when the claim is received for processing.
Does NIA Magellan
allow retroprecertifications?
Yes. However, it is important that rendering facility staff be
educated on the precertification requirements. Claims for the
following non-emergent procedures.
Yes. If they initiate the process, NIA Magellan will follow-up
with the ordering physician to complete the process.
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Can a provider
verify a
precertification
number online?
Will the NIA
Magellan
precertification
CT/CTA
MRI/MRA
PET Scan
CCTA
Myocardial Perfusion Imaging (MPI)
Stress Echocardiography(Effective December1, 2015)
Implantable Cardiac Devices (Effective December1, 2015)
Cardiac Catheterization (Effective December1, 2015)
Musculoskeletal (Effective January 1, 2014)
Will not be reimbursed if they have not been properly
precertified. The rendering facility should not schedule
services without precertification.
Yes. Providers can check the status of member
precertification’s quickly and easily by going to the NIA
Magellan website at www.RadMD.com.
No
5—HMSA – Frequently Asked Questions
number be displayed
on the HMSA
website?
SCHEDULING SERVICES
How will NIA
NIA Magellan manages the Advanced Diagnostic Imaging,
Magellan determine Interventional Pain Management, Spine Surgery, and
where to schedule
Cardiac Solutions, are managed through HMSA contractual
Medical Specialty
relationships.
Solutions Services
for HMSA member?
Why does NIA
During the precertification process, NIA Magellan asks
Magellan ask for a
where the procedure is being performed and the anticipated
date of service when date of service. The exact date of service is not required,
precertifying a
with the exception of Interventional Pain Management.
procedure? Do
Physicians should obtain precertification before scheduling
physicians have to
the patient.
obtain a
precertification
before the services
are rendered?
WHICH MEDICAL PROVIDERS ARE AFFECTED?
Which medical
Any provider who orders Medical Specialty Solution
providers are
procedure. Ordering providers will need to request a
affected by the
precertification and the delivering/servicing providers will
Medical Specialty
need to ensure there is a precertification number in order to
Solutions Services?
bill the service.
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CLAIMS RELATED
Where do providers
send their claims for
outpatient, nonemergent Medical
Specialty Solutions
Ordering providers, including Primary Care
Providers (PCPs) and Specialty Care providers.
Delivering/Servicing providers who perform
Medical Specialty Solutions Services at:
o Freestanding diagnostic facilities
o Ambulatory Surgical Centers
o Hospital outpatient diagnostic facilities
o Provider offices
Providers should continue to send claims to the address
indicated on the back of the HMSA member ID card.
Providers are also encouraged to follow their normal EDI
claims process.
6—HMSA – Frequently Asked Questions
Services?
How can providers
check claims status?
Who should a
provider contact if
they want to appeal
a precertification or
claims payment
denial?
MISCELLANEOUS
How is medical
necessity defined?
Providers should check claims status at the HMSA claim
website at: https://hhin.hmsa.com/.
In the event of a precertification or claims payment denial,
providers may appeal the decision through HMSA. Providers
should follow the instructions on their non-precertification
letter or Explanation of Payment (EOP) notification.
NIA Magellan defines medical necessity as a service that:
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Where can a
provider find NIA
Magellan’s
Guidelines for
Medical Specialty
Solutions Services?
What will the
Member ID card
Meets generally accepted standards of medical
practice; is appropriate for the symptoms,
consistent with diagnosis, and otherwise in
accordance with sufficient evidence and
professionally recognized standards;
Is appropriate to the illness or injury for which
it is performed as to type of service and
expected outcome;
Is appropriate to the intensity of service and
level of setting;
Provides unique, essential, and appropriate
information when used for diagnostic purposes;
Is the lowest cost alternative that effectively
addresses and treats the medical problem; and
rendered for the treatment or diagnosis of an
injury or illness; and
Is not furnished primarily for the convenience of
the member, the attending physician, or other
provider.
NIA Magellan’s Clinical Guidelines for the aforementioned
Medical Specialty Solution Services can be found on NIA
Magellan’s Website at www.RadMD.com. The guidelines are
presented in a PDF file format that can easily be printed for
future reference. NIA Magellan’s clinical guidelines have
been developed from practice experiences, literature reviews,
specialty criteria sets and empirical data.
The HMSA Member ID card will not contain any NIA
Magellan identifying information on it.
7—HMSA – Frequently Asked Questions
look like? Will the
ID card have both
NIA Magellan and
HMSA information
on it? Or will there
be two cards?
What is an OCR Fax By utilizing Optical Character Recognition (OCR) technology,
Coversheet?
NIA Magellan can automatically attach incoming clinical
faxes to the appropriate case in our clinical system. We
strongly recommend that ordering providers print an OCR
fax coversheet from www.RadMD.com or contact NIA
Magellan at 1-866-306-9729 to request an OCR fax
coversheet if their precertification request is not approved
on-line or during the initial phone call to NIA Magellan. NIA
Magellan can fax this coversheet to the ordering provider
during precertification intake or at any time during the
review process. By prefacing clinical faxes to NIA Magellan
with an OCR fax coversheet, the ordering provider can
ensure a timely and efficient case review.
CONTACT INFORMATION
Who can a provider
Providers can contact, Kevin Apgar, Provider Relations
contact at NIA
Manager, at 1-800-450-7281, ext. 65080 OR 916-859-5080
Magellan for more
information?
8—HMSA – Frequently Asked Questions