NIA Magellan 1 Spine Care Program Interventional Pain Management Frequently Asked Questions (FAQs) For Medicare Advantage HMO and PPO

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1 NIA Magellan 1 Spine Care Prgram Interventinal Pain Management Frequently Asked Questins (FAQs) Fr Medicare Advantage HMO and PPO Questin GENERAL Why is Flrida Blue implementing a Spine Management prgram fcused n interventinal pain management prcedures? Answer T imprve quality and manage the utilizatin f nn-emergent spine care, including interventinal pain management (IPM) prcedures. NIA Magellan is the vendr manager fr the Flrida Blue advanced imaging prgram and these new spine mdalities are an extensin f that management prgram. Flrida Blue prviders will utilize the prvider tls t request these studies as they d tday fr advanced imaging. Interventinal Pain Prcedures include: Why did Flrida Blue select NIA Magellan? Which Flrida Blue members will be cvered under this relatinship and what netwrks will be used? PROGRAM START DATE What is the implementatin date fr this Spine management prgram? PRIOR AUTHORIZATION What Spine Management services will require a prvider t btain a prir authrizatin? Spinal Epidural Injectins Paravertebral Facet Jint Injectins r Blcks Paravertebral Facet Jint Denervatin (Radifrequency Neurlysis) An affiliate f Magellan Health Services, NIA Magellan was selected t partner with Flrida Blue because f its clinically driven prgram designed t effectively manage the quality, patient safety and ensure apprpriate utilizatin f resurces fr Medicare Advantage HMO and PPO membership. NIA Magellan will manage nn-emergent utpatient interventinal pain management spine prcedures fr Medicare Advantage BlueMedicare HMO and BlueMedicare PPO fr the prgram as f January 1, The prgram start date is January 1, Flrida Blue and NIA Magellan will cllabrate n prvider related activities prir t the start date including prvider annuncements and prvider educatin. The fllwing prcedures require prir authrizatin thrugh NIA Magellan: Spinal Epidural Injectins Paravertebral Facet Jint Injectins r Blcks 1 NIA Magellan refers t Natinal Imaging Assciates, Inc. 1 Flrida Blue Medicare Frequently Asked Questins Interventinal Pain Management

2 When is prir authrizatin required? Is prir authrizatin required fr members currently underging treatment? Wh d we expect t rder Spine interventinal pain management prcedures Are inpatient Interventinal Pain Management (IPM) prcedures included in this prgram? Des the setting f the service affect the required prir authrizatin? Hw des the rdering prvider btain a prir authrizatin frm NIA Magellan fr an utpatient interventinal pain management prcedure? What infrmatin will NIA Magellan require in rder t receive prir authrizatin? Paravertebral Facet Jint Denervatin (Radifrequency Neurlysis) Prir authrizatin is required fr utpatient, nn-emergent interventinal pain prcedures. Ordering prviders must btain prirauthrizatin f these prcedures prir t the service being perfrmed. Nte: Only utpatient prcedures are within the prgram scpe. All interventinal pain management prcedures perfrmed in the emergency rm r as part f inpatient care d nt require prir authrizatin. Yes. Authrizatin is required fr dates f service n r beynd January 1, 2016 even if the member is cntinuing treatment. Interventinal pain prcedures requiring medical necessity review are usually rdered by ne f the fllwing specialties. Anesthesilgists Neurlgists Pain Specialist Orthpedic Spine Surgen Neursurgen Other physicians with apprpriate pain prcedure training and certificatin Inpatient interventinal pain management prcedures are nt included in this prgram. N. The medical necessity review and determinatin are fr the authrizatin f prfessinal services. Any prir authrizatin requirements fr a facility must still be btained separately. Prviders will be able t request prir authrizatin via the NIA Magellan website r by calling the NIA Magellan tll-free number T expedite the prcess, please have the fllwing infrmatin ready befre lgging n t the website r calling the NIA Magellan call center staff (*dentes required infrmatin): Interventinal Pain Management Prcedures: Name and ffice phne number f rdering physician* Member name and ID number* Requested prcedure* Name f prvider ffice r facility where the service will be perfrmed* Anticipated date f service* Details justifying the pain prcedure*: 2 Flrida Blue Medicare Frequently Asked Questins Interventinal Pain Management

3 Date f nset f pain r exacerbatin Physician exam findings and patient symptms (including findings applicable t the requested services) Clinical Diagnsis Date and results f prir interventinal pain management prcedures. Diagnstic imaging results, where available. Cnservative treatment mdalities cmpleted, duratin, and results (e.g., physical therapy, chirpractic r stepathic manipulatin, ht pads, massage, ice packs and medicatin) Please be prepared t fax the fllwing infrmatin, if requested: Can a prvider request mre than ne prcedure at a time fr a member (i.e., a series f epidural injectins)? What kind f respnse time can rdering prviders expect fr prir authrizatin? Clinical ntes utlining nset f pain, cnservative care mdalities, utcmes and physical exam findings Date and results f prir interventinal pain management prcedures Effectiveness f prir prcedures n reducing pain Diagnstic Imaging results Specialist reprts/evaluatin N. NIA Magellan requires prir authrizatin fr each pain prcedure being requested and will nt authrize mre than ne prcedure at a time. The best way t maximize the efficiency turnarund time f an authrizatin request nline thrugh r thrugh the tll-free number, (866) , is t have knwledge f the case including: The patient s histry and diagnsis Onset f pain Findings n physical examinatin Respnse and type f nn-perative management the patient has undergne Histry f medical r surgical treatment Ratinale fr the prcedure What will the NIA Magellan authrizatin number lk like? Generally, within 2 business days after receipt f request with full clinical dcumentatin, a determinatin will be made. In certain cases, the review prcess can take lnger if additinal clinical infrmatin is required t make a determinatin. The NIA Magellan authrizatin number will cnsist f 8 r 9 alphanumeric characters. In sme cases, the rdering prvider may receive an NIA Magellan tracking number instead (nt the same as an authrizatin number) if the prvider s authrizatin request is nt apprved at the time f initial cntact. Prviders will be able t use either number t track the status f their request nline r thrugh an Interactive Vice Respnse (IVR) telephne system. 3 Flrida Blue Medicare Frequently Asked Questins Interventinal Pain Management

4 If an authrizatin is requested thrugh RadMD and the request pends, what happens next? Can RadMD be used t request retrspective r expedited authrizatin request? Hw lng is the prir authrizatin number valid? If a prvider btains a prir authrizatin number des that guarantee payment? Des NIA Magellan allw retr-authrizatins? What happens if I have a service scheduled fr January 1, 2016? Can a prvider verify an authrizatin number nline? Yu will receive a tracking number and NIA Magellan will cntact yu t cmplete the prcess. N. Thse requests will need t be called int NIA Magellan s Call Center thrugh the tll free numberat fr prcessing. The authrizatin number is valid fr 90 days frm the date f service. An authrizatin number is nt a guarantee f payment. Authrizatins are based n medical necessity and are cntingent upn eligibility and benefits. Benefits may be subject t limitatins and/r qualificatins and will be determined when the claim is received fr prcessing. It is imprtant that key physicians and ffice staff be educated n the prir authrizatin requirements. Claims fr interventinal pain management prcedures, as utlined abve, that have nt been prperly authrized will nt be reimbursed. Physicians administering these prcedures shuld nt schedule r perfrm prcedures withut prir authrizatin. Retrspective review f cmpleted prcedures are evaluated fr medical necessity and t determine whether there was an urgent r emergent situatin that prhibited the prvider frm btaining prir authrizatin fr the service and t determine whether medical necessity guidelines were met. An authrizatin can be btained fr all pain management prcedures fr dates f service January 1, 2016 and beynd. NIA Magellan and Flrida Blue will wrk with the prvider cmmunity n an nging basis t cntinue t educate prviders that authrizatins are required. Yes. Prviders can check the status f member authrizatin quickly and easily by ging t the website at Will the NIA Magellan authrizatin number be displayed n the Flrida Blue Web site? What if I disagree with NIA Magellan s determinatin? SCHEDULING PROCEDURES Will NIA Magellan make a final determinatin based n the anticipated date f service? N. In the event f a prir authrizatin r claims payment denial, prviders may appeal the decisin thrugh Flrida Blue. Prviders shuld fllw the instructins n their nn-authrizatin letter r Explanatin f Payment (EOP) ntificatin. NIA Magellan des nt guarantee final determinatin f the request by the anticipated date f service. The anticipated date f service (prvided during request fr authrizatin) is used t determine timing between prcedures. 4 Flrida Blue Medicare Frequently Asked Questins Interventinal Pain Management

5 WHICH MEDICAL PROVIDERS ARE AFFECTED? Which medical prviders are affected by the Spine Management Prgram? Please be advised that NIA Magellan needs 2 business days after the receipt f clinical infrmatin t review and render a decisin n a request. Please d nt schedule r perfrm the prcedure until yu have an apprved authrizatin. Specialized prviders wh perfrm Interventinal Pain Management (IPM) spine prcedures in an utpatient setting. Flrida Blue prviders will need t request a prir authrizatin frm NIA Magellan in rder t bill the service. Prviders wh perfrm IPM prcedures are generally lcated at: CLAIMS RELATED Where d prviders send their claims fr utpatient, nn-emergent pain management services? Hw can prviders check claims status? Wh shuld a prvider cntact if they want t appeal a prir authrizatin r claims payment denial? MISCELLANEOUS Hw is medical necessity defined? Hw will referring/rdering prviders knw wh NIA Magellan is? Will prvider trainings be Ambulatry surgical centers Hspital utpatient facilities Prvider ffices Flrida Blue netwrk prviders shuld cntinue t send claims directly t Flrida Blue. Prviders are encuraged t use EDI claims submissin. Prviders shuld cntinue t check claims status with Flrida Blue at : Prviders are asked t please fllw the appeal instructins given n their nn-authrizatin letter r Explanatin f Benefits (EOB) ntificatin. Medical necessity means services that: Meets generally accepted standards f medical practice; be apprpriate fr the symptms, cnsistent with diagnsis, and therwise in accrdance with sufficient evidence and prfessinally recgnized standards; Are apprpriate t the illness r injury fr which it is perfrmed as t type f service and expected utcme; Are apprpriate t the intensity f service and level f setting; Prvide unique, essential, and apprpriate infrmatin when used fr diagnstic purpses; Are the lwest cst alternative that effectively addresses and treats the medical prblem; and rendered fr the treatment r diagnsis f an injury r illness; and Nt furnished primarily fr the cnvenience f the member, the attending physician, r ther prvider. Flrida Blue will mail ntificatin letters and educatinal materials t prviders. Flrida Blue and NIA Magellan are als cnducting educatinal trainings fr prviders. Yes, NIA Magellan will cnduct webinar training sessins prir t the 5 Flrida Blue Medicare Frequently Asked Questins Interventinal Pain Management

6 ffered clser t the January 1, 2016 implementatin date? Where can a prvider find NIA Magellan s Guidelines fr Clinical Use f Pain Management Prcedures? What will the member ID card lk like? Will the ID card have bth NIA Magellan and Flrida Blue infrmatin n it? Or will there be tw cards? CONTACT INFORMATION Wh can a prvider cntact at NIA Magellan fr mre infrmatin? implementatin date. NIA Magellan s Interventinal Pain Management Prcedures Guidelines can be fund n the website at r n They are presented in a PDF file frmat that can easily be printed fr future reference. NIA Magellan s clinical guidelines have been develped frm practice experiences, literature reviews, specialty criteria sets and empirical data. The Flrida Blue Member ID card will nt change and will nt cntain any NIA Magellan identifying infrmatin n it. Prviders can cntact Michele DeCapri, Manager f Prvider Relatins at (800) ext Flrida Blue Medicare Frequently Asked Questins Interventinal Pain Management