Natinal Imaging Assciates, Inc. (NIA) Frequently Asked Questins (FAQs) Fr Luisiana Healthcare Cnnectins Prviders Questin GENERAL Why did Luisiana Healthcare Cnnectins implement a Medical Prgram? Answer Effective February 1, 2012, we implemented a Medical Prgram t imprve quality and manage the utilizatin f the fllwing nn-emergent prcedures. CT/CTA MRI/MRA CCTA Effective July 1, 2016: Mycardial Perfusin Imaging (MPI) MUGA Scan Echcardigraphy Stress Echcardigraphy What is the pst service review prgram? Why did Luisiana Healthcare Cnnectins select NIA t manage its Medical Prgram? Which Luisiana Healthcare Cnnectins members will be cvered under this Pst Service Review (N Prir Authrizatin Required) *Physical, Occupatinal and Speech Therapy *Pst service review: Effective March 1, 2018, Physical, Occupatinal and Speech Therapy services claims will be reviewed by NIA peer cnsultants t determine whether the services met/meet Luisiana Healthcare Cnnectins plicy criteria fr medically necessary and medically apprpriate care. Physical, Occupatinal and Speech Therapy services will NOT require prir authrizatin when rendered by a participating prvider. A subsidiary f Magellan Health, NIA was selected t partner with Luisiana Healthcare Cnnectins because f their clinically driven prgram designed t effectively manage quality and patient safety while ensuring apprpriate utilizatin f resurces fr Luisiana Healthcare Cnnectins membership. NIA manages the Diagnstic Imaging Services (MR/CT) thrugh its cntractual relatinships with free standing facilities. NIA s Medical Specialty Slutins (Cardiac Imaging and Pst Service 1 Luisiana Healthcare Cnnectins - Frequently Asked Questins
relatinship and what netwrks will be used? UTILIZATION MANAGEMENT What is the Implementatin Date fr the Medical Prgram? What Medical Specialty Slutins Services require prviders t btain a prir authrizatin? Review) are managed thrugh Luisiana Healthcare Cnnectins cntractual relatinships. The implementatin date fr radilgy services was February 1, 2012. Pst service therapy review will begin March 1, 2018. The fllwing nn-emergent, utpatient, Medical services require prir authrizatin thrugh NIA: Effective February 1, 2012: CT/CTA MRI/MRA CCTA Effective July 1, 2016: Mycardial Perfusin Imaging (MPI) MUGA Scan Echcardigraphy Stress Echcardigraphy Emergency rm, bservatin and inpatient prcedures d nt require prir authrizatin frm NIA. If an urgent/emergent clinical situatin exists utside f a hspital emergency rm, please cntact NIA immediately with the apprpriate clinical infrmatin fr an expedited review. D ut f netwrk prviders require prir authrizatin fr therapy services? Is prir authrizatin necessary fr sedatin with an MRI? Is an NIA authrizatin number needed fr a CTguided bipsy? Can a chirpractr rder images? Are rutine imaging services a part f this prgram? Out-f-netwrk prviders must cntact Luisiana Healthcare Cnnectins t register therapy services. N, prir authrizatin is nt required fr sedatin when perfrmed with an MRI. N, prir authrizatin is nt required fr this prcedure. Yes. N. 2 Luisiana Healthcare Cnnectins - Frequently Asked Questins
Are inpatient diagnstic imaging prcedures included in this prgram? Is prir authrizatin required fr Medical Services perfrmed in the emergency rm? Hw des the rdering prvider btain a prir authrizatin frm NIA fr an utpatient diagnstic imaging service? What infrmatin is required in rder t receive prir authrizatin fr utpatient diagnstic imaging services? N. Inpatient prcedures are included in the authrizatin fr the inpatient stay that is managed thrugh the Luisiana Healthcare Cnnectins Medical Management Department. N. Medical Services perfrmed in the emergency rm are nt included in this prgram and d nt require prir authrizatin thrugh NIA. Prviders are able t request prir authrizatin via the internet (www.radmd.cm) r by calling NIA at 1-866-326-6301. T expedite the prir authrizatin prcess, please refer t the specific required dcumentatin fr each Medical Specialty Slutin. Have the apprpriate infrmatin ready befre lgging int NIA s Web site r calling NIA s Call Center (*Infrmatin is required): Name and ffice phne number f rdering physician* Member name and ID number* Requested examinatin* Name f prvider ffice r facility where the service will be perfrmed* Anticipated date f service Details justifying examinatin.* Symptms and their duratin Physical exam findings Cnservative treatment patient has already cmpleted (e.g., physical therapy, chirpractic r stepathic manipulatin, ht pads, massage, ice packs, medicatins) Preliminary prcedures already cmpleted (e.g., x-rays, CTs, lab wrk, ultrasund, scped prcedures, referrals t specialist, specialist evaluatin) Reasn the study is being requested (e.g., further evaluatin, rule ut a disrder) Please be prepared t prvide the fllwing infrmatin, if requested: 3 Luisiana Healthcare Cnnectins - Frequently Asked Questins
Clinical ntes X-ray reprts Previus related test results Specialist reprts/evaluatin Ultrasund reprts Can a prvider request mre than ne service at a time fr a member? What kind f respnse time can rdering prviders expect fr prir authrizatin? What des the NIA authrizatin and/r tracking number lk like? RADIOLOGY If requesting authrizatin thrugh RadMD and the request pends, what happens next? Can RadMD be used t request an expedited authrizatin request? What happens if a patient is authrized fr a service and the prvider feels an additinal study is needed? *T assist in cllecting infrmatin fr the authrizatin prcess, yu may access the specific medical specialty (prir authrizatin r treatment plan checklists) n www.radmd.cm. NIA can handle multiple authrizatin requests per cntact. Separate authrizatin numbers are issued by NIA fr each service that is authrized. 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 authrizatin number cnsists f 10 alpha-numeric characters. In sme cases, the rdering prvider may receive an NIA tracking number (nt the same as an authrizatin number) if the prvider s authrizatin request is nt apprved at the time f initial cntact. Prviders can use either number t track the status f a case nline r thrugh an Interactive Vice Respnse (IVR) telephne system. Yu will receive a tracking number and NIA will cntact yu t cmplete the prcess. N, expedited requests will need t be called int NIA s Call Center fr prcessing. If the prvider feels that, in additin t the service already authrized, an additinal service is needed, please cntact NIA immediately with the apprpriate clinical infrmatin fr an expedited review. The number t call t btain prir authrizatin is 1-866-326-6301. 4 Luisiana Healthcare Cnnectins - Frequently Asked Questins
Can the rendering facility btain authrizatin in the event f an urgent service? If a prvider btains a prir authrizatin number des that guarantee payment? Des NIA allw retrauthrizatins? Yes. If they initiate the prcess, NIA will fllw-up with the rdering physician t cmplete the prcess. 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. Yes. Hwever, it is imprtant that rendering facility staff be educated n the prir authrizatin requirements. Claims fr the fllwing nnemergent utpatient services will nt be reimbursed if they have nt been prperly authrized: CT/CTA MRI/MRA CCTA Mycardial Perfusin Imaging (MPI) MUGA Scan Echcardigraphy Stress Echcardigraphy Can a prvider verify an authrizatin number nline? Will the NIA authrizatin number be displayed n the Luisiana Healthcare Cnnectins website? SCHEDULING SERVICES Hw will NIA determine where t schedule Medical Services fr a Luisiana Healthcare Cnnectins member? The rendering facility shuld nt schedule services withut prir authrizatin. Yes. Prviders can check the status f member authrizatins quickly and easily by ging t the NIA web site at www.radmd.cm. N. NIA manages the Diagnstic Imaging Services (MR/CT) thrugh its cntractual relatinships with free standing facilities. NIA s Medical Specialty Slutins (Cardiac Imaging and Pst Service Review) are managed thrugh Luisiana Healthcare Cnnectins cntractual relatinships. 5 Luisiana Healthcare Cnnectins - Frequently Asked Questins
Why des NIA ask fr a date f service when authrizing a prcedure? D physicians have t btain an authrizatin befre the services are rendered? WHICH MEDICAL PROVIDERS ARE AFFECTED? Which medical prviders are affected by the Medical Services? During the authrizatin prcess, NIA asks where the prcedure is being perfrmed and the anticipated date f service. The exact date f service is nt required, with the exceptin f Interventinal Pain Management. Physicians shuld btain authrizatin befre scheduling the patient. Any prvider wh rders Medical Specialty Slutin Services in an utpatient setting. Ordering prviders will need t request a prir authrizatin and the delivering/servicing prviders will need t ensure there is an authrizatin number in rder t bill the service. CLAIMS RELATED Where d prviders send their claims fr utpatient, nn-emergent Medical 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? Ordering prviders, including Primary Care Prviders (PCPs) and Specialty Care prviders. Delivering/Servicing prviders wh perfrm Medical Services at: Freestanding diagnstic facilities Ambulatry Surgical Centers Hspital utpatient diagnstic facilities Prvider ffices Radiatin Treatment Facilities Prviders shuld cntinue t send claims t the address indicated n the back f the Luisiana Healthcare Cnnectins member ID card. Prviders are als encuraged t fllw their nrmal EDI claims prcess. Prviders shuld check claims status at the Luisiana Healthcare Cnnectins claim website at: www.luisianahealthcnnect.cm. In the event f a prir authrizatin r claims payment denial, prviders may appeal the decisin thrugh Luisiana Healthcare Cnnectins. Prviders shuld fllw the instructins n their nn-authrizatin letter r Explanatin f Payment (EOP) ntificatin. NIA defines medical necessity as a service that: 6 Luisiana Healthcare Cnnectins - Frequently Asked Questins
Where can a prvider find NIA s Guidelines fr Medical Services? What will the Member ID card lk like? Will the ID card have bth NIA and Luisiana Healthcare Cnnectins infrmatin n it, r will there be tw cards? What is an OCR Fax Cversheet? Meets generally accepted standards f medical practice; is apprpriate fr the symptms, cnsistent with diagnsis, and therwise in accrdance with sufficient evidence and prfessinally recgnized standards; Is apprpriate t the illness r injury fr which it is perfrmed as t type f service and expected utcme; Is apprpriate t the intensity f service and level f setting; Prvides unique, essential, and apprpriate infrmatin when used fr diagnstic purpses; Is 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 Is nt furnished primarily fr the cnvenience f the member, the attending physician, r ther prvider. NIA s Clinical Guidelines fr the afrementined Medical Specialty Slutin Services can be fund n NIA s Web site at www.radmd.cm. The guidelines are presented in a PDF file frmat that can easily be printed fr future reference. NIA s clinical guidelines have been develped frm practice experiences, literature reviews, specialty criteria sets and empirical data. The Luisiana Healthcare Cnnectins Member ID card will nt cntain any NIA identifying infrmatin n it. By utilizing Optical Character Recgnitin (OCR) technlgy, NIA can autmatically attach incming clinical faxes t the apprpriate case in ur clinical system. We strngly recmmend that rdering prviders print an OCR fax cversheet frm www.radmd.cm r cntact NIA at 1-866-500-7656 t request an OCR fax cversheet if their authrizatin request is nt apprved nline r 7 Luisiana Healthcare Cnnectins - Frequently Asked Questins
CONTACT INFORMATION Wh can a prvider cntact at NIA fr mre infrmatin? during the initial phne call t NIA. NIA can fax this cversheet t the rdering prvider during authrizatin intake r at any time during the review prcess. By prefacing clinical faxes t NIA with an OCR fax cversheet, the rdering prvider can ensure a timely and efficient case review. Prviders can cntact April Sabin, Prvider Relatins Manager, at 1-800-450-7281 ext. 31078 OR 1-410-953-1078 OR ajsabin@magellanhealth.cm. 8 Luisiana Healthcare Cnnectins - Frequently Asked Questins