Musculoskeletal Program - PDF Free Download

Today s agenda Agenda AIM overview How the program works Accessing ProviderPortal SM Demonstration of joint and pain request process Blue Cross of Idaho program elements Q & A 2 2019 AIM Specialty Health All Rights Reserved.

AIM overview 3.

Who is AIM Specialty Health? AIM Specialty Health (AIM) is a leading specialty benefits management company who partners with Blue Cross of Idaho (BCI) on a variety of clinical appropriateness review programs that promote the standard of care. Our innovative and physician-centric experience fueled by our dedicated people, efficient process, and user-friendly tools creates value for health plans across the country. Advanced Imaging Sleep Medicine Musculoskeletal Spine (Pain and Joint New for 2019)

Our nationally recognized team of clinical leaders ensures credibility in our approach to each solution ROBERT MANDEL STACEY BAN CHRIS BUCKLE VARSHA CHANDRAMOULI RAHUL DHAWAN Senior Vice President and Chief Medical Officer Medical Director, Oncology Programs Medical Director, Radiology Vice President, Clinical Operations Associate Medical Director, Government Programs (Medicaid) and Nephrology JENNIFER ECKLUND MICHAEL J. FISCH ROBERT FURNO WILLIAM ROBERT MARTIN III THOMAS P. POWER Associate Medical Director, Government Programs Medical Director, Medical Oncology Programs and Genetics Medical Director, Government Programs (Medicare) Medical Director, Musculoskeletal Senior Medical Director, Cardiology and Sleep Medicine KERRIE REED Medical Director, Rehabilitation JULIE THIEL Senior Vice President, Clinical Programs RICHARD VALDESUSO Senior Medical Director, Musculoskeletal ROBERT ZIMMERMAN Medical Director, Radiation Oncology 5

How the program works 6.

Program specifics IMPORTANT DATES Commercial & Medicare Advantage COVERED MEMBERSHIP Interventional Pain Joint Surgery CLINICAL DOMAIN March 25 th, 2019 CALL CENTER OPEN DATE ~5mins AVERAGE TIME TO INITIATE A CASE ONLINE April 1st, 2019 PROGRAM LAUNCH DATE 7 2018 AIM Specialty Health All Rights Reserved.

What s different from current health plan program? Review Enhancements Interventional Pain 3 Days IMPROVED TURNAROUND TIME FOR PAIN AND JOINT SURGERY REQUESTS WITH AIM Specialty Matched MD Reviewers INTERVENTIONAL PAIN SPECIALISTS AND JOINT SURGEONS AVAILABLE FOR PEER TO PEER DISCUSSIONS Joint Surgery 8

Multidisciplinary team supports our program Neuroradiology Leveraging the clinical experience from our core Radiology program, our deep clinical expertise creates tremendous value for a comprehensive spine and interventional pain management program. Neuro & Orthopedic Spine For the Musculoskeletal program, we have a variety of spine surgeons affiliated with AIM to drive the most appropriate use of spine procedures. Anesthesiology To promote the standards of care for interventional pain management, our clinical bench includes boardcertified anesthesiology resources who guide the development of evidence-based guidelines Orthopedic Joint & Sports Medicine Clinical subject matter experts in this domain provide guideline support and consulting on prevailing practices across the country. AIM incorporates physician feedback from the leading professional societies to encourage quality care Physical medicine and rehabilitation Knowing the specialty integration necessary with spine and pain management procedures, the AIM comprehensive program includes subject matter experts in physical medicine More than 30% of AIM clinical team members maintain an active practice (3+ clinic days per month) 9

Clinical review workflow Standard pre-service clinical review steps 1 Case intake 2 Case adjudication 3 Education and intervention 4 Case closure 5 Additional review options Member demographics Requesting provider and facility demographics Clinical case information Document upload (if applicable) Clinical appropriateness adjudication against AIM guidelines Clinical appropriateness adjudication against health plan medical policy Messaging on appropriateness of request and link to guidelines Peer-to-peer discussion if previous adjudication indicated that case is inappropriate Document final review outcome Messaging of final review outcome to provider Denial and approval letter generation Extract case information to health plan Pre-service reconsiderations Pre-service provider document review 1 st level provider appeals managed by AIM 10

Order request check list Demographic information Clinical information Member first and last name and date of birth Order provider first and last name CPT code(s) and the name of the procedure you are requesting Date of the procedure and type of facility (i.e. inpatient, outpatient hospital, office, or ambulatory surgery center) Requested procedure laterality (right, left, or bilateral) Spine levels and region (if applicable) Co-morbidities or surgical risk factors (if applicable) Refer to the AIM MSK microsite for more details: http://aimproviders.com/msk Anticipated need for a co-surgeon, assistant surgeon, or surgical assistant (if applicable) Various documentation supporting medical necessity 11

Program scope Procedures included in the program Interventional pain management Joint surgery Epidural Injections (Interlaminar/Caudal and Transforaminal) Facet Joint Injections/ Medial Branch Blocks Facet Joint Radiofrequency Nerve Ablation Implanted Spinal Cord Stimulators Regional Sympathetic Blocks Sacroiliac Joint Injections Total Hip Replacement Total Knee Replacement Shoulder Arthroplasty Hip Arthroscopy Knee Arthroscopy Shoulder Arthroscopy 12

Clinical appropriateness review - Pain Interventional pain management Included settings: Frequency of injections Results of prior injections Duration of therapy Longitudinal record and the capture of previous procedure history Conservative Treatment Ambulatory surgical center Outpatient hospital Physician s office 13

Clinical appropriateness review - Joints Total joint and arthroscopy Included settings: Level of pain Level of function Imaging report Conservative treatment Smoking cessation Weight reduction to achieve a BMI <40 Ambulatory surgical center Inpatient hospital Outpatient hospital 14

Accessing ProviderPortal 15.

Accessing ProviderPortal SM Blue Cross of Idaho s portal for physicians continues to be the gateway into the AIM online initiation tool. Log in to access. Entry of User Info 16 2018 AIM Specialty Health All Rights Reserved.

Accessing ProviderPortal SM Hover over Authorization & Notifications then come to Prior Authorization Procedure Code Lookup to see status of the code(s) 17 2018 AIM Specialty Health All Rights Reserved.

Accessing ProviderPortal SM Enter the patient information, then Search. When patient is found then select Enter Procedure Code. Enter all codes for the episode and dates of service. Select Search then results will display. If an authorization is needed select the hyperlink in the text to go to enter the authorization. Last name 01/01/1970 Last name, first name Birth Date: 01/01/1970 Enrollee ID: IDxxxxxxxxx Enrollment Status: Active *The results could tell you the code doesn t require an authorization or point you to the correct system to complete the authorization. 19 2018 AIM Specialty Health All Rights Reserved.

Provider Portal Demo 23.

ProviderPortal process 24

ProviderPortal process 25

ProviderPortal process 26

ProviderPortal process 27

ProviderPortal process Spine surgery, interventional pain management or joint surgery 28

ProviderPortal process If member has other orders, they will show up in the member history. 29

ProviderPortal process 30

ProviderPortal process 31

ProviderPortal process 32

ProviderPortal process 33

ProviderPortal process 34

ProviderPortal process 35

ProviderPortal process If the requesting and servicing provider are the same, answer yes to copy the provider information 36

ProviderPortal process 37

ProviderPortal process 38

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ProviderPortal process 42

ProviderPortal process If no additional clinical review is needed, the summary page will show the authorization number for the request. 43

Part II: Provider documentation review (PDR) 44 2018 AIM Specialty Health.

ProviderPortal process The provider documentation review allows you to provide additional clinical information not previously submitted for a denied case if the request is received within 10 calendar days of the date of determination for commercial members. On portal, search for the order and select the nonauthorized case. 45

ProviderPortal process Attaching the additional information to the case triggers the provider documentation review to begin. Closed case will be reopened for further review using the additional information. 46

BC Idaho Program elements 47.

Submitting an order request Access AIM ProviderPortal through Blue Cross of Idaho Portal Available 24 hours/day, 7 days/week (except for maintenance on Sundays from 12-6 p.m. CST) ProviderPortal ProviderPortal Support Team can be reached through the below toll free number AIM Clinical Guidelines available on ProviderPortal Dedicated toll-free number: 1-866-714-1105 Dedicated clinical navigator line: (224) 278-5110 AIM Contact Center Contact center hours: Mon Fri, 8am to 6pm MDT Voice mail received after business hours will be responded to the next business day * AIM call center is closed on the following holidays: Thanksgiving Day, Day after Thanksgiving, Christmas Day, New Year s Day, Martin Luther King Jr. Day, Memorial Day, Independence Day, and Labor Day. 48

How long is a case valid? Joint Surgery Interventional Pain Management ORDER NUMBER EXPIRES: ORDER NUMBER EXPIRES: 6 30 MONTHS from the date the case was created CALENDAR DAYS from the date of service 49

Time period of review process will perform Prospective reviews 7 calendar day retrospective review Reconsiderations for Commercial cases up to 10 calendar days with additional information. Emergent (ER) requests Concurrent stay reviews >7 day retro review will perform 1 st level provider appeals for Commercial cases up to 180 days from date of service 50

Program start date MARCH 25 APRIL 01 2019 2019 Contact Center and ProviderPortal opens Program Go Live Contact center and ProviderPortal will be available beginning on 3/25/2019 for preauthorization requests with dates of service rendered on or after 4/1/2019 51

Reference Materials 52.

55. Questions?