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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. 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 : 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 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. 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. 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: 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