Peach State Health Plan Ordering Provider Training for OB Ultrasounds

1. Peach State Health Plan Ordering Provider Training for OB Ultrasounds

2. Ordering Provider Training Program Agenda for OB Ultrasounds • Welcome and Opening Remarks • About NIA • The OB Ultrasound Program Requirements • NIA OB Ultrasound Management • Comparison to current OB US Program • The Prior Authorization Process • The Authorization Appeals Process • The Claims Process • The Claims Appeals Process • Provider Self-Service Tools (RadMD and IVR) • RadMD Demo • NIA Provider Relations and Contact Information • Questions and Answers

3. About NIA NIA is accredited by NCQA and URAC certified • National Imaging Associates (NIA) -- chosen as the solution for National and Regional Health Plans covering more than 19 million lives due to: • Distinctive clinical focus. • Accredited by NCQA and URAC certified. • Innovation and Stability -- Parent is Magellan Health Services – The depth and breadth of our experience in managing behavioral health care, diagnostic imaging, specialty pharmaceutical services, pharmacy benefits administration and obstetrical ultrasounds enables us to deliver invaluable insights and innovative solutions that positively impact both the quality and cost of some of the nation’s fastest growing areas of health care. • Focus / Results: Maximizing diagnostic services value; promoting patient safety through: • A clinically-driven process that safeguards appropriate diagnostic treatment for Peach State Health Plan members.

4. The OB Ultrasound Program and Authorization Process

5. OB Ultrasound Program Requirements –Initial Procedures • Peach State Health Plan and National Imaging Associates, Inc. (NIA) will incorporate OB Ultrasound procedures into the existing radiology management program effective December 1, 2010. • Providers will continue to contact Peach State Health Plan for these procedures prior to December 1, 2010. • The first one (1) to two (2) OB ultrasounds do not require prior authorization or registration when standard CPT codes are used. • Providers can bill one CPT code from any two of the following three groups: • 76801 or 76817 for the first trimester. • 76805 or 76811 for second trimester (76811 should only be used for the second US when the diagnosis is 642.xx, 646.xx, 648.xx or 796.5). • 76816 for the third trimester (when first US is not done until second trimester) • One nuchal measure (76813) is also allowed and does not count against the first one (1) to two (2). • Claims submitted that are outside of the CPT codes noted above will not be paid. • NIA will not be conducting any privileging activities on behalf of Peach State Health Plan.

6. OB Ultrasound Program Requirements –Beyond Initial Procedures • OB Ultrasounds beyond the initial one (1) to two (2) require prior authorization. • Prior authorization beyond the initial one (1) to two (2) will apply to the following CPT Codes: 76805, 76811, 76815, 76816, 76817, 76818, 76819, 76820 and 76821. • When a pregnancy has specific serious complications that meet our criteria, multiple ultrasounds may be authorized with one request. • Only Ultrasounds done for confirmed pregnancies will be covered. A pregnancy test should occur first to confirm the pregnancy. Ultrasounds to confirm a pregnancy will not be approved. • Any condition that does not result in an authorization at intake, will be discussed with an Initial Clinical Reviewer – ICR (such as a nurse) and/or Physician Clinical Reviewer - PCR ( a Maternal Fetal Medicine (MFM) specialist) if additional information is needed.

7. NIA OB Ultrasound Management NIA’s OB US Management Approach Recognizes Unique Population Challenges

8. Comparison to current OB US program • Both the CURRENT PSHP OB US management program and the NEW NIA program allow the initial 1-2 procedures without prior authorization. • Most pregnancies can be managed with the initial 1-2 procedures. • A “nuchal measure” is also allowed and does not count against the first 1-2. • The NIA program allows the authorization of multiple ultrasounds for specific, verified medical or obstetrical conditions, such as diabetes, hypertension, hypothyroid disease, multiple gestation, etc.  • Many complex pregnancies will only require 1 call. • Physician reviews, when required, will be conducted by a Maternal Fetal Medicine specialist.

9. NIA Prior-Authorization is required for: • OB ultrasounds beyond the initial procedures previously listed require prior authorization, including: • Multiple ultrasounds for specific, verified medical or obstetrical conditions, such as diabetes, hypertension, hypothyroid disease, multiple gestation, etc. • Ultrasounds when performed as a component of antepartum testing. • The standard approach for antepartum testing is a Non-Stress Test (NST) with, or without an Amniotic Fluid Value (AFV) via a limited ultrasound (76815) – i.e. “modified biophysical profile”. • A “full” biophysical profile (NST plus four ultrasound components of Fetal Movement (FM), Fetal Tone (FT), Amniotic Fluid Volume (AFV) and Fetal Breath Movement (FBM)) is not considered necessary if the NST is reactive. • Prior authorization for biophysical profiles (76818 or 76819) is required and these requests will be clinically reviewed.

10. NIA Prior-Authorization is not required for: • Inpatient OB Ultrasound services • Observation setting OB Ultrasound services • Emergency Room OB Ultrasound services rendered in a hospital or urgent care center

11. NIA’s Authorization Process • The ordering physician is responsible for obtaining prior authorization for OB Ultrasound services beyond the initial one (1) to two (2) ultrasounds and nuchal measure. • It is the responsibility of the rendering physician (if different than the ordering physician) to ensure that prior authorization was obtained. Payment will be denied for procedures performed without prior authorization and the member cannot be balance-billed for such procedures. • The rendering provider must ensure that an authorization has been obtained and it is recommended that you not schedule procedures without prior authorization. • Authorizations are valid for 30 days from the date of the request. When a procedure is authorized, NIA will use the date of the request as the starting point for the 30-day period in which the examination must be completed. For some pregnancies with specific medical conditions, an authorization for multiple procedures may be valid up to delivery. • In the event that a service is delivered on an urgent basis in an office setting without prior authorization, a request can be submitted the same business day or the health plan will consider information submitted with the claim by the rendering provider (e.g., supporting medical records and the reason the service was not prior authorized) when considering payment of the claim.  • Retrospective requests (requests submitted after the day of service) will not be permitted and will be managed via the Peach State Health Plan claims appeals process.

12. NIA OCR Fax Cover Sheet – Submission of Clinical Information • NIA utilizes OCR technology which allows us to attach the clinical information that you send to be automatically attached to an existing prior authorization request. • For the automatic attachment to occur you must use the NIA Fax Cover Sheet as the first page of your fax. •  You can obtain an NIA Fax Cover Sheet in the following ways. • If you have submitted your prior authorization request on-line through RadMD, at the end of your submission of the prior authorization request you are given the option to print the cover sheet. • On RadMD click on the link “Request a Fax Cover Sheet”. This will allow you to print the cover sheet for a specific patient. • By calling the NIA Clinical Support Department at 888-642-7649 you can request a cover sheet be faxed to you. • If we have sent you a fax requesting additional clinical information the NIA Fax Cover Sheet should accompany the request. • Following this process will ensure a timely and efficient case review.

13. The NIA Prior Authorization Process P P P Nurse level Agent level MFM/Physician* level Procedure is authorized by agent Procedure is authorized by nurse Physician’s office contacts NIA for prior authorization via web or telephone Procedure is authorized by a physician reviewer Procedure is denied by a physician reviewer x ? Case is transferred to nurse for review ? Case is transferred to physician for review Case is administratively withdrawn by the ordering physician x • When a pregnancy has specific serious complications that meet our criteria, multiple ultrasounds may be authorized with one request. • Physician reviewers for OB US Requests are Maternal Fetal Medicine (MFM) Specialists NIA—A Magellan Health Company 13

14. The Authorization Appeals Process

15. The Authorization Appeals Process • Utilization review decisions are made in accordance with currently accepted medical or healthcare practices, taking into account special circumstances of each case that may require deviation from the norm stated in the screening criteria. Criteria are used for the approval of medical necessity but not for the denial of services. The Medical Director reviews all potential denials of medical necessity decision. • Appeals related to a medical necessity decision made during the authorization, pre-certification or concurrent review process can be made orally or in writing to: Medical Management Administrative Review Coordinator 3200 Highlands Parkway SE, Ste 300 Smyrna, GA 30082 • Providers and members have the right to request a copy of the review criteria or benefit provision utilized to make a denial decision. Copies of the criteria can be obtained by submitting your request in writing to: Medical Management 3200 Highlands Parkway, SE, Ste. 300 Smyrna, GA 30082 Attn: IQ Criteria • Providers may obtain the criteria used to make a specific decision and discuss denial decisions with the physician reviewer who made the decision by calling the Medical Management Department at 1-800-704-1483, Monday - Friday, between the hours of 8am and 5:30 pm.

16. The Authorization Appeals Process The plan shall allow Medicaid members that have exhausted the internal appeals process related to a denied service, the option either to pursue the administrative law hearing or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the Medicaid member and the plan are unable to agree on association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section 49-4-153 shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the plan and the Medicaid member mutually agree to extend this deadline. All costs of arbitration, not including attorney’s fees, shall be shared equally by the parties. You must exhaust all of the Plan’s internal Appeals Processes prior to requesting an Administrative Law Hearing or binding arbitration. All arbitration costs will be shared by the Plan and the Medicaid member. Requests should be mailed to: Peach State Health Plan Manager, Appeals 3200 Highlands Parkway Suite 300 Smyrna, GA 30082 PeachCare for Kids Members should send their final appeal directly to the Department of Community Health. NIA—A Magellan Health Company 16

17. The Claims Process

18. How Claims Should be Submitted • Providers should continue to send claims directly to the address indicated on the back of the Peach State Health Plan member ID card. • Providers are strongly encouraged to use EDI claims submission. • Providers should continue to check on claims status by logging on to the Peach State Health Plan Web site www.pshpgeorgia.com.

19. The Claims Appeals Process

20. The Claims Appeals Process • In the event of a claims payment denial, providers may file a Reconsideration. • A provider may also appeal the decision through Peach State Health Plan. • All Claim appeals require a Provider Appeal Request Form which must be completed and submitted with supporting documentation. Providers may batch multiple claim appeals that are similar in nature. The Provider Appeal Request Form may be found in the Provider Forms section of the Peach State website, www.pshpgeorgia.com. Send Claim Appeals to: Peach State Health Plan PO Box 3000 Farmington, MO 63640-3812 • An acknowledgement letter will be sent within ten (10) business days of receipt of the appeal. If the initial claim determination is upheld, the provider will be notified in writing within thirty (30) business days of Peach State’s receipt of the claim appeal. If the initial claim determination is overturned, the provider will be notified through a newly issued EOP. • If you are still not satisfied with the outcome of the appeal, you have the option of choosing an Administrative Law Hearing or Binding Arbitration. The request for an Administrative Law Hearing or Binding Arbitration must be submitted within fifteen (15) days of receipt of the plan’s decision. Requests received after this time frame will not be considered.

21. The Claims Appeals Process The plan shall allow a provider that has exhausted the internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal, the option either to pursue the administrative law hearing or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the plan and the provider are unable to agree on association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this Code section 49-4-153 shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 days of being selected, unless the plan and the provider mutually agree to extend this deadline. All costs of arbitration, not including attorney’s fees, shall be shared equally by the parties. You must exhaust all of the Plan’s internal Appeal Processes prior to requesting an Administrative Law Hearing or binding arbitration. All arbitration costs will be shared by the Plan and the Provider. Requests should be mailed to: Peach State Health Plan Manager, Claim Appeals 3200 Highlands Parkway Suite 300 Smyrna, GA 30082 NIA—A Magellan Health Company 21

22. Self Service Tools and Usage

23. Multi-Channel Provider Relations Strategy • Internet Offerings • Initiate Authorization (Ordering Provider) • Authorization Inquiry RadMD.com / MagellanHealth.com • IVR – Interactive Voice Response • Authorization Inquiry Interactive Voice Response OBUS Provider High Touch • Provider Relations Staff • Provider Forums/Education • Centralized and Regional Support

24. Self Service Tools and Usage Interactive Voice Response (IVR) • Use tracking number to check status of cases Web site: www.RadMD.com • Use tracking number to review an exam request

25. NIA Website www.RadMD.com • Information on prior authorization requests can be viewed at www.RadMD.com after login with username and password • Providers may search based on the patient’s ID number, name or authorization number

26. NIA Web Site • RadMD is a user-friendly, near-real-time Internet tool offered by NIA. • Hours of Operation: 24/7 • RadMD provides instant access to much of the authorization information that our Call Center staff provides, but in an easily accessible Internet format. • We encourage all ordering providers to submit all requests online at RadMD. • With RadMD, the majority of cases will be authorized online with ease; however, we will resolve pended cases through our Clinical Review department. • We strongly recommend that ordering providers print an OCR Fax Coversheet from RadMD if their authorization request is not approved online or during the initial phone call to NIA. By prefacing clinical faxes to NIA with an OCR fax coversheet, the ordering provider can ensure a timely and efficient case review. • RadMD provides up-to-the-hour information on member authorizations, including date initiated, date approved, exam category, valid billing codes and more.

27. NIA Web Site • User-friendly, near-real-time Internet tool offered by NIA • Log on to RadMD.com Web site offers access to: • Member authorization • Date initiated • Exam requested • Valid billing codes (CPT)

28. To get started, visit www.RadMD.com • Click the “New User” button on the right side of the home page. • 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 NIA-approved user name and password. • Everyone in your organization is required to have his or her own separate user name and password due to HIPAA regulations. • On subsequent visits to the site, click the “Login” button to proceed. • If you use RadMD for another Health Plan with NIA, you may use the same log on and password for Peach State Health Plan.

29. RadMD Demo

30. NIA Provider Relations

31. Provider Relations Structure and Portals • Providing educational tools to ordering providers on OB Ultrasound program processes and procedures. • NIA Provider Relations Manager • Anthony (Tony) Salvati • Phone: 1-314-387-5537 • Email: alsalvati@magellanhealth.com • NIA Network Services • Phone: 1-800-327-0641

32. Questions and Answers