Musculoskeletal Prior Authorization for Highmark...This presentation contains CONFIDENTIAL and...

© 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

Musculoskeletal Prior Authorization for Highmark

Provider Orientation

© eviCore healthcare. All Rights Reserved.

This presentation contains CONFIDENTIAL and PROPRIETARY information.

Company Overview

2

Radiology

Cardiology

Musculoskeletal

Sleep Management

Medical Oncology

Specialty Drug

Radiation Therapy

Lab Management

Post-Acute Care

9 Comprehensive

Solutions



3

Comprehensive

Solutions 9 The industry’s most

comprehensive clinical

evidence-based guidelines

4k+ employees including

1k clinicians

Engaging with 570k+ providers

100M Members

Managed

Nationwide

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Headquartered in Bluffton, SC and offices across the US

including:

• Melbourne, FL

• Plainville, CT

• Sacramento, CA

• Lexington, MA

• Colorado Springs, CO

• Franklin, TN

• Greenwich, CT

Musculoskeletal Management Solution - Our Experience

30+ Regional and National Clients

Members Managed

• 25.5M Commercial Memberships

• 2M Medicare Memberships

• 6.5M Medicaid Memberships

300k+

Cases built per day

40M members managed nationwide

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10 Years Managing Radiation Therapy Services

6

Clinical Staffing

44 Musculoskeletal

physicians on staff

66

Musculoskeletal-trained

nurses on staff

40 Million lives

covered

56 Musculoskeletal

therapists (PT/OT/ST/MT/CHIRO/ACU)



Our Clinical Approach

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Multi-Specialty Expertise

• 190+ board-certified medical

directors

• Diverse representation of medical

specialties

• 450 nurses with diverse

specialties and experience

• Dedicated nursing and physician

teams by specialty for

Cardiology, Oncology, OB-GYN,

Spine/Orthopedics, Neurology,

and Medical/Surgical

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Clinical Platform

Family Medicine

Internal Medicine

Pediatrics

Sports Medicine

OB/GYN

Cardiology

Nuclear Medicine

Anesthesiology

Radiation Oncology

Sleep Medicine

Oncology/Hematology

Musculoskeletal

• Orthopedic

Surgery

• Spine Surgery

• Interventional

Pain

Radiology

• Nuclear Medicine

• Musculoskeletal

• Neuroradiology

• American Academy of Neurology

• American College of Rheumatology

• American Association of Neurological Surgeons

• American Academy of Orthopedic Surgeons

• American Society of Interventional Pain Physicians

• North American Spine Society

• American College of Occupational and

Environmental Medicine

• American Academy of Physical Medicine and

Rehabilitation

• American Association of Hip and Knee Surgeons

• American Pain Society

• Official Disability Guidelines

• Medicare Guidelines

• Spine Intervention Society

• American Academy of Orthopedic Surgeons

• The American Orthopedic Society for Sports Medicine

• Cochrane Reviews

• American Physical Therapy Association

• American Chiropractic Association

• American Occupational Therapy Association

• American Speech Language Hearing Association

• American Society of Anesthesiologists

Evidence-Based Guidelines

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The foundation of our musculoskeletal solution:

Aligned with National Societies

Dedicated

pediatric

guidelines

Medicare

LCDs & NCDs

Academic

institutional

experts and

community

physician panels

Current

clinical

literature

The Client Provider Operations team is responsible for high-level service delivery to

our health plan clients as well as ordering and rendering providers nationwide

Client Provider Operations

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Best Colors

Client Provider

Representatives

are cross-trained to

investigate escalated

provider and health

plan issues.

Client Provider

Representatives

Client Experience

Managers lead

resolution of complex

service issues and

coordinate with partners

for continuous

improvement.

Client Experience

Managers

Regional Provider Engagement

Managers are on-the-ground

resources who serve as the voice of

eviCore to the provider community.

Regional Provider

Engagement Managers

Why Our Service Delivery Model Works

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One centralized intake point

allows for timely identification,

tracking, trending, and reporting

of all issues. It also enables

eviCore to quickly identify and

respond to systemic issues

impacting multiple providers.

Complex issues are escalated

to resources who are the

subject matter experts and can

quickly coordinate with matrix

partners to address issues at a

root-cause level.

Routine issues are handled by

a team of representatives who

are cross trained to respond to a

variety of issues. There is no

reliance on a single individual to

respond to your needs.

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Musculoskeletal

Prior Authorization Program

for Highmark

eviCore will begin accepting requests on September 24, 2018 for dates of service October 1,

2018 and beyond

Program Overview

13

Prior authorization applies

to services that are:

• Outpatient

• Inpatient

• Elective / Non-emergent

Prior authorization

does not apply* to services

that are performed in:

• Emergency room

• Observation stay

It is the responsibility of the rendering provider to verify that the

necessary authorization has been obtained before providing the service.

*An urgent unplanned inpatient hospital stay must be authorized

through Highmark, with the hospital providing notification and clinical

information for the inpatient request within 48 hours of the urgent

unplanned admission.

Applicable Membership

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Prior authorization by eviCore is required for Highmark members in

Pennsylvania, Delaware and West Virginia enrolled in the following programs:

• Commercial Fully Insured

• Medicare Advantage

• Affordable Care Act

Highmark will manage prior authorizations for MSK surgeries or IPM

services for all other members according to the member's benefits.

Benefits can vary by member contract, so please be sure to check the

member's benefits before delivering care to confirm if an

authorization is required. NaviNet® is available to help you check

member benefits and to verify if an authorization is required.

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Prior Authorization Required:

To find a list of CPT

(Current Procedural Terminology)

codes that require prior authorization

through eviCore, please visit:

https://www.evicore.com/healthplan/highmark

Joint Surgery

• Large joint replacement (Includes Hip, Knee, and Shoulder

• Arthroscopic and open procedures (Includes Hip, Knee, and

Shoulder)

Spine Surgery

• Spinal Implants

• Electrical bone growth stimulators

• Pain Pumps (Implantable intrathecal drug delivery

system)

• Graft (Implant – Allograft/Autograft)

• Cervical/Thoracic/Lumbar

• Decompressions

• Fusions

• Total Disc Arthroplasty (Cervical/Lumbar)

• Vertebroplasty/Kyphoplasty

• Microdiscectomy (Cervical/Lumbar)

Interventional Pain

• Spinal injections (Includes Sacroiliac Joint, Epidural steroid

injections, Facet Joint injections, Regional Sympathetic

Blocks)

• Chemodenervation – Botulinum Toxin Injections

• Radiofrequency Joint Ablation Denervation

• Spinal implants

• Spinal cord stimulators

• Pain pumps (Implantable intrathecal drug delivery

system)





How to request prior authorization:

Prior Authorization Requests

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Or by phone*:

888-564-5492

7:00 a.m. to 7:00 p.m.

EST

Monday - Friday

WEB

NaviNet®

Available 24/7 and the quickest

way to create prior authorizations

and check existing case status

Fax* option: 800.540.2406 Fax forms available at www.evicore.com

*For members managed by Highmark, NaviNet remains the preferred method. If phone or fax submission is needed the Highmark phone

and fax numbers should be used.

http://www.evicore.com/

Clinical Review Process

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Easy for

providers

and staff

START

Methods of Intake

Nurse

Review

Predictive

Intelligence/Clinical

Decision Support

Appropriate

Decision

MD

Review

Clinical

Consultation

Real-Time Decision with Web and Phone

Needed Information

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Member Member ID

Member name

Date of birth (DOB)

Facility Facility name

National provider identifier (NPI)

Tax identification number (TIN)

Street address

Rendering/Ordering Physician

Physician name

National provider identifier (NPI)

Tax identification number (TIN)

Fax number

i Requests

CPT code(s) for

requested procedure

The appropriate

diagnosis code for the

working of differential

diagnosis

If clinical information is needed, please be able to supply:

• Imaging studies and prior test results related to the diagnosis

• Office notes related to the current diagnosis

Prior Authorization Outcomes

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• All requests are processed within 2 business days

after receipt of all necessary clinical information.

• Authorizations are typically good for 60 calendar

days from the date of determination.

• Highmark will honor existing prior authorizations for

continuity of care on claims for MSK surgeries or

IPM services that overlap during the transition to the

new program.

Approved Requests:

• Faxed to ordering provider

• Mailed to the member

• Information can be printed on demand from the

Highmark provider web portal

Delivery:

• Communication of denial determination

• Communication of the rationale for the denial

• How to request a Peer Review for commercial

members

• Faxed to the ordering provider

• Mailed to the member

• Information can be printed on demand from the

Highmark provider web portal

Delivery:

Denied Requests:

Delivery:

Prior Authorization Outcomes – Commercial

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• Additional clinical information can be provided

without the need for a physician to participate

• Must be requested on or before the anticipated date

of service

• Commercial members only

Reconsiderations

Peer-to-Peer Review

• If a request is denied and requires further clinical

discussion for approval, we welcome requests for

clinical determination discussions from referring

physicians. In certain instances, additional

information provided during the consultation is

sufficient to satisfy the medical necessity criteria for

approval.

• Peer-to-Peer reviews can be scheduled at a time

convenient to your physician

• Commercial members only

Peer-to-Peer Review:

Prior Authorization Outcomes – Medicare / Medicare Advantage

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• If your case requires further clinical discussion for approval, we welcome

requests for clinical determination discussions from referring physicians

prior to a decision being rendered.

• In certain instances, additional information provided during the pre-

decision consultation is sufficient to satisfy the medical necessity criteria

for approval

Pre-Decision Consultation

Special Circumstances

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Retrospective Reviews:

• Retro requests must be submitted within 730

business days following the date of service.

Requests submitted after 730 business days will be

administratively denied.

• Retro requests can be submitted via phone or fax.

• Retro requests are reviewed for medical necessity.

Turnaround time on retro requests is 30 calendar

days.

• Retro requests for dates of service before

10/1/2018 must be submitted to Highmark

Urgent Outpatient Studies:

• Contact eviCore by phone to request an expedited

outpatient prior authorization review and provide

clinical information

• Urgent Outpatient Cases will be reviewed within 24

hours not to exceed 72 hours of the request.

• eviCore will process first level provider appeals for

Commercial members.

• Requests for appeals must be submitted to

eviCore within 365 calendar days of the initial

determination

• The procedure request and all clinical information

provided will be reviewed by a physician other

than the one who made the initial determination.

• A written notice of the appeal decision will be

mailed to the member and faxed to the provider

• Highmark will process first level provider appeals

for Medicare Advantage members.

• Appeals for services that were denied before

10/1/2018 must be submitted to Highmark

Medical Necessity Appeals:

Special Circumstances

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• Spine surgery and joint surgery prior

authorizations can be extended for 60 days.

Please contact eviCore by phone to request a

date extension.

• Interventional Pain prior authorizations are not

eligible for date extensions.

Date Extensions:

Interventional Pain Management: Epidural Steroid Injections

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• There is insufficient scientific evidence to support

the scheduling of a “series-of-three” injection in

either a diagnostic or therapeutic approach.*

• The medical necessity of subsequent injections

should be evaluated individually and be based on

the response of the individual to the previous

injection with regard to clinically relevant

sustained reductions in pain, decreased need for

medication and improvement in the individual’s

functional abilities*

Series-of-three:

* Please refer to eviCore’s evidence based guidelines www.evicore.com


Spinal Surgery: Smoking Cessation

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• Highmark has made the decision not to enforce

at this time smoking cessation as a requirement

in the spinal surgery medical necessity criteria.

Highmark promotes evidence-based health care

and shared decision-making to inform patients

and practitioners on how to achieve the best

health outcomes.

Smoking cessation:

* Please refer to eviCore’s evidence based guidelines www.evicore.com


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Web Portal Services



Single-Sign On for Highmark Providers

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A category for Musculoskeletal / lnterventional Pain Management

has been added to the Eligibility and Benefits screen in NaviNet

to indicate if authorization is required.




Inpatient - Providers must select either Large Joint

Procedures or Spine Surgery Procedures under the

Service selection




Outpatient - Providers must select either Pain

Management Procedures, Large Joint Procedures or

Spine Surgery Procedures under the Service selection




The Referred To Facility must be provided for inpatient authorizations. If the

Referred to Facility is not provided, the claim may be denied.



Contact Information

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Confirm the Provider’s name and appropriate

information for the point of contact individual.



Member History

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This is the Member History screen. If the patient has a history of requests from the

provider it will populate on this screen.



Verify Service Selection

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ICD-10 Code

ICD-10 Code



Clinical Certification

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• Verify all information entered and make any needed changes prior to moving

into the clinical collection phase of the prior authorization process.

• You will not have the opportunity to make changes after that point.



Pause/Save Option

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Once you have entered the clinical collection phase of the case process, you can save

the information and return within (2) business days to complete.



Medical Review

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Acknowledge the Clinical Certification statements, and hit “Submit Case.”

Approval

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Once the clinical pathway

questions are completed

and the answers have met

the clinical criteria, an

approval will be issued.

Print the screen and store

in the patient’s file.



Medical Review

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If additional information is required, you will have the option to either upload

documentation, enter information into the text field, or contact us via phone.

Authorization look up

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Select Search by Authorization Number/NPI. Enter the provider’s NPI and authorization or

case number. Select Search.

You can also search for an authorization by Member Information, and enter the health

plan, Provider NPI, patient’s ID number, and patient’s date of birth.



Authorization Status

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The authorization will then be accessible to review. To print authorization

correspondence, select View Correspondence.



Provider Resources

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Musculoskeletal Online Resources

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Clinical Guidelines, FAQ’s, Online Forms, and other important resources can be

accessed at www.evicore.com. Click “Solutions” from the menu bar, and select the

specific program needed.




Musculoskeletal Online Resources

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Clinical Worksheets and Fax Forms can be accessed at www.evicore.com. Click

“Resources” & “Providers” from the menu bar. Click “Online Forms &

Resources”& Select Solution “Musculoskeletal” from the dropdown menu.




eviCore Provider Blog Series

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• The eviCore blog series focuses on making processes more efficient and easier

to understand by providing helpful tips on how to navigate prior authorizations,

avoid peer-to-peer phone calls, and utilize our clinical guidelines.

• You can access the blog publications from the Insights tab or via the direct link

at https://www.evicore.com/pages/media.aspx.

https://www.evicore.com/pages/media.aspx

https://www.evicore.com/pages/media.aspx



Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Prior Authorization Call Center

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7:00 AM - 7:00 PM (EST): (888) 564-5492*

• Obtain pre-certification or check the status of an existing case

• Discuss questions regarding authorizations and case decisions

• Change facility or CPT Code(s) on an existing case

• To request a Clinical Consultation

• Status checks

eviCore fax* number: (800) 540-2406

*For members managed by Highmark, NaviNet remains the preferred method. If phone or fax submission is needed

the Highmark phone and fax numbers should be used.



Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Web-Based Services

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www.evicore.com

To speak with a Web Specialist*, call (800) 646-0418 (Option #2) or

email [email protected].

• Pause/Start feature to complete initiated cases

• Upload electronic PDF/word clinical documents

*For issues with NaviNet, click on Help at the top of Highmark Plan Central to access NaviNet Support


mailto:[email protected]



Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Client Provider Operations

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[email protected]

• Issues experienced while building a prior authorization request

• Reports of eviCore system issues

8:00 AM – 8:00 PM (EST): (800) 575-4517





Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Implementation Document

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Higmark Implementation site - includes all implementation

documents:


• Provider Orientation Presentation

• CPT code list of the procedures that require prior authorization

• Quick Reference Guide

• eviCore clinical guidelines

• FAQ documents and announcement letters

Materials are also available on the Highmark Provider Resource

Center Site under Care Management Programs

You can obtain a copy of this presentation on the implementation site listed

above. If you are unable to locate a copy of the presentation, please contact

the Client Provider Operations team at [email protected].






Thank You!

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Musculoskeletal Prior Authorization for Highmark...This presentation contains CONFIDENTIAL and...

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