Natinal Imaging Assciates, Inc. (NIA) Frequently Asked Questins (FAQ s) Fr PA Health & Wellness Prviders Questin GENERAL Why is PA Health & Wellness implementing a Medical Specialty Slutins Prgram? Answer We are implementing a Medical Specialty Slutins Prgram t imprve quality and manage the utilizatin f the fllwing nnemergent prcedures. CT/CTA MRI/MRA PET Scan CCTA MUGA Scan Mycardial Perfusin Imaging (MPI) Why did PA Health & Wellness select NIA t manage its Medical Specialty Slutins Prgram? Which PA Health & Wellness participants will be cvered under this relatinship and what netwrks will be used? PRIOR AUTHORIZATION What is the Implementatin Date fr the Medical Specialty Slutins Prgram? A subsidiary f Magellan Health, NIA was selected t partner with PA Health & Wellness because f their clinically driven prgram designed t effectively manage quality and patient safety, while ensuring apprpriate utilizatin f resurces fr PA Health & Wellness membership. NIA will manage the Diagnstic Imaging Services (MR/CT/PET) thrugh its cntractual relatinships with free standing facilities. NIA s Medical Specialty Slutins fr Cardiac Imaging will be managed thrugh PA Health & Wellness cntractual relatinships. Implementatin will be January 1, 2018. 1 PA Health & Wellness - Frequently Asked Questins
What Medical Specialty Slutins Services require prviders t btain a prir authrizatin? The fllwing nn-emergent, utpatient, Medical Specialty Slutins services require prir authrizatin thrugh NIA: Effective January 1, 2018: Diagnstic Imaging (MR, CT/CCTA, PET), MUGA Scan and Mycardial Perfusin Imaging (MPI) 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? Are inpatient Diagnstic Imaging (MR, CT/CCTA, PET,) MUGA and Mycardial Perfusin Imaging (MPI) prcedures included in this prgram? Is prir authrizatin required fr Medical Specialty Slutins Services perfrmed in the emergency rm? Hw des the rdering prvider btain a prir authrizatin frm NIA fr an utpatient Diagnstic Imaging service? 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. N, prir authrizatin is nt required fr sedatin when perfrmed with an MRI. N, prir authrizatin is nt required fr this prcedure. N. N. N. Inpatient prcedures are included in the authrizatin fr the inpatient stay that is managed thrugh the PA Health & Wellness Medical Management Department. N. Medical Specialty Slutins Services perfrmed in the emergency rm are nt included in this prgram and d nt require prir authrizatin thrugh NIA. Prviders will be able t request prir authrizatin via the internet (www.radmd.cm) r by calling NIA at: 1-800-424-4921 Medicaid 1-866-642-9705 Medicare 2 PA Health & Wellness - Frequently Asked Questins
What infrmatin is required in rder t receive prir authrizatin? 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 Clinical ntes X-ray reprts Previus related test results Specialist reprts/evaluatin Ultrasund reprts *T assist in cllecting infrmatin fr the authrizatin prcess, yu may access the specific medical specialty (prir authrizatin checklists) n www.radmd.cm. 3 PA Health & Wellness - Frequently Asked Questins
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 number lk like? 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? 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 their request 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: 1-800-424-4921 Medicaid 1-866-642-9705 Medicare Can the rendering facility btain authrizatin in the event f an urgent service? Yes. If they initiate the prcess, NIA will fllwup with the rdering physician t cmplete the prcess. 4 PA Health & Wellness - Frequently Asked Questins
If a prvider btains a prir authrizatin number des that guarantee payment? Des NIA allw retrauthrizatins? 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 nn-emergent utpatient services: Diagnstic Imaging (MR, CT/CCTA, PET), MUGA and Mycardial Perfusin Imaging (MPI). Will nt be reimbursed if they have nt been prperly authrized. The rendering facility shuld nt schedule services withut prir authrizatin. What happens if I have a service scheduled fr January 1, 2018? An authrizatin can be btained fr all Medical Specialty Slutins fr dates f service January 1, 2018 and beynd, beginning January 1, 2018. NIA and PA Health & Wellness will be wrking with the prvider cmmunity n an nging basis t cntinue t educate prviders that authrizatins are required. Can a prvider verify an authrizatin number nline? Will the NIA authrizatin number be displayed n the PA Health & Wellness web site? Yes. Prviders can check the status f member authrizatins quickly and easily by ging t the NIA web site at www.radmd.cm. N. SCHEDULING SERVICES 5 PA Health & Wellness - Frequently Asked Questins
Hw will NIA determine where t schedule Medical Specialty Slutins Services fr PA Health & Wellness participants? 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 Specialty Slutins Services? CLAIMS RELATED Where d prviders send their claims fr utpatient, nnemergent Medical Specialty Slutins Services? Hw can prviders check claims status? NIA manages the Diagnstic Imaging Services (MR/CT/PET) thrugh its cntractual relatinships with free standing facilities. NIA s Medical Specialty Slutins fr Cardiac Imaging are managed thrugh PA Health & Wellness cntractual relatinships. During the authrizatin prcess, NIA asks where the prcedure is being perfrmed and the anticipated date f service. 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. Ordering prviders, including Primary Care Prviders (PCPs) and Specialty Care prviders. Delivering/Servicing prviders wh perfrm Medical Specialty Slutins Services at: Freestanding diagnstic facilities Ambulatry Surgical Centers Hspital utpatient diagnstic facilities Prvider ffices Prviders shuld cntinue t send claims t the address indicated n the back f the PA Health & Wellness member ID card. Prviders are als encuraged t fllw their nrmal EDI claims prcess. Prviders shuld check claims status at the PA Health & Wellness claim website at: www.pahealthwellness.cm. 6 PA Health & Wellness - Frequently Asked Questins
Wh shuld a prvider cntact if they want t appeal a prir authrizatin r claims payment denial? MISCELLANEOUS Hw is medical necessity defined? Where can a prvider find NIA s Guidelines fr Medical Specialty Slutins Services? In the event f a prir authrizatin r claims payment denial, prviders may appeal the decisin thrugh PA Health & Wellness. Prviders shuld fllw the instructins n their nn-authrizatin letter r Explanatin f Payment (EOP) ntificatin. NIA defines medical necessity as a service that: 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. 7 PA Health & Wellness - Frequently Asked Questins
What will the Member ID card lk like? Will the ID card have bth NIA and PA Health & Wellness infrmatin n it? Or will there be tw cards? What is an OCR Fax Cversheet? CONTACT INFORMATION Wh can a prvider cntact at NIA fr mre infrmatin? The PA Health & Wellness 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 [ telephne number] t request an OCR fax cversheet if their authrizatin request is nt apprved n-line r 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, Charmaine Everett, Prvider Relatins Manager, at 1-800-450-7281 ext. 32615. 8 PA Health & Wellness - Frequently Asked Questins