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

Prior Authorization Provider Orientation for Oscar

Provider Orientation 2019

© eviCore healthcare. All Rights Reserved.

This presentation contains CONFIDENTIAL and PROPRIETARY information.

Comprehensive

Solutions9The industry’s most

comprehensive clinical

evidence-based guidelines

4k+ employees including

1k clinicians

Engaging with 570k+ providers

Advanced, innovative, and

intelligent technology

100M Members

Managed

Nationwide

2

Headquartered in Bluffton, SC

Offices across the US including:

• Melbourne, FL

• Plainville, CT

• Sacramento, CA

• Lexington, MA

• Colorado Springs, CO

• Franklin, TN

• Greenwich, CT

© eviCore healthcare. All Rights Reserved.

This presentation contains CONFIDENTIAL and PROPRIETARY information.

Radiology

Cardiology

Musculoskeletal

Sleep Management

Medical Oncology

Specialty Drug

Radiation Therapy

Lab Management

Post-Acute Care

End-to-End Solution

Integrated platform

9 Comprehensive

Solutions

© eviCore healthcare. All Rights Reserved.

This presentation contains CONFIDENTIAL and PROPRIETARY information. 3

4

Our Clinical Approach

• 260 board-certified medical

directors

• Diverse representation of medical

specialties

• 800 nurses with diverse

specialties and experience

• Dedicated nursing and physician

teams by specialty for Radiology,

Cardiology, Oncology, OB-GYN,

Spine/Orthopedics, Neurology,

and Medical/Surgical

5

Clinical Platform

Family Medicine

Internal Medicine

Pediatrics

Sports Medicine

OB/GYN

Cardiology

Nuclear Medicine

Anesthesiology

Radiation Oncology

Sleep Medicine

Oncology/Hematology

Surgery

• General

• Orthopedic

• Thoracic

• Cardiac

• Neurological

• Otolaryngology

• Spine

Radiology

• Nuclear Medicine

• Musculoskeletal

• Neuroradiology

Multi-Specialty Expertise

The foundation of our solutions:

6

Evidence-Based Guidelines

Aligned with National Societies

Dedicated

pediatric

guidelines

Contributions

from a panel

of community

physicians

Experts

associated

with academic

institutions

Current

clinical

literature

• American College of Therapeutic Radiology and

Oncology

• American Society for Radiation Oncology

• American Society of Clinical Oncology

• American Academy of Pediatrics

• American Society of Colon and Rectal Surgeons

• North American Spine Society

• American Association of Neurological Surgeons

• American College of Obstetricians and

Gynecologists

• The Society of Maternal-Fetal Medicine

• American College of Cardiology

• American Heart Association

• American Society of Nuclear Cardiology

• Heart Rhythm Society

• American College of Radiology

• American Academy of Neurology

• American College of Chest Physicians

• American College of Rheumatology

• American Academy of Sleep Medicine

• American Urological Association

• National Comprehensive Cancer Network

7

Service Model

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

8

Client Provider Operations

Best Colors

Client Provider

Representatives

are cross-trained to

investigate escalated

provider and health

plan issues.

Client Provider

Representatives

Client Service Managers

lead resolution of

complex service issues

and coordinate with

partners for continuous

improvement.

Client Service

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

9

Why Our Service Delivery Model Works

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.

Portal Compatibility

10

The eviCore.com website is compatible with the following web browsers:

• Google Chrome

• Mozilla Firefox

• Internet Explorer 9, 10, and 11

You may need to disable pop-up blockers to access the site. For information on

how to disable pop-up blockers for any of these web browsers, please refer to our

Disabling Pop-Up Blockers guide.

eviCore healthcare website

• Login or Register

• Point web browser to evicore.com

• Click on the “Providers” link

Creating An Account

12

To create a new account, click Register.

Creating An Account

13

Select CareCore National and complete the user registration form.

You will be able to access the MedSolutions portal as well.

Creating An Account

14

Review information provided, and click “Submit Registration.”

User Registration-Continued

15

Accept the Terms and Conditions, and click “Submit.”

User Registration-Continued

16

You will receive a message on the screen confirming your registration is

successful. You will be sent an email to create your password.

Create a Password

17

Uppercase letters

Lowercase letters

Numbers

Characters (e.g., ! ? *)

Your password must be at

least (8) characters long

and contain the following:

Account Log-In

18

To log-in to your account, enter your User ID and Password. Agree to

the HIPAA Disclosure, and click “Login.”

Welcome Screen

19

• Providers will need to be added to your account prior to case submission. Click the

“Manage Account” tab to add provider information.

• Note: You can access the MedSolutions Portal at any time without having to provide

additional log-in information. Click the MedSolutions Portal button on the top right corner

to seamlessly toggle back and forth between the two portals.

Add Practitioners

20

Click the “Add Provider” button.

Add Practitioners

21

Enter the Provider’s NPI, State, and ZIP Code to search for the provider record to add

to your account. You are able to add multiple providers to your account.

Adding Practitioners

22

Select the matching record based upon your search criteria

Manage Your Account

23

• Once you have selected a practitioner, your registration will be completed.

You can then access the “Manage Your Account” tab to make any necessary

updates or changes.

• You can also click “Add Another Practitioner” to add another provider to your

account.

24

Web Portal Overview

Legacy CareCore National Portal

eviCore will begin accepting requests on 12/15/19 for dates of service

1/1/19 and beyond

25

Authorization Update

Prior authorization applies

to services that are:

• Outpatient

• Elective / Non-emergent

• Diagnostic

Prior authorization

does not apply to services

that are performed in:

• Emergency room

• 23-hour observation

• Inpatient

It is the responsibility of the ordering provider to request prior authorization approval for

services.

** Inpatient requests will continue to be handled by Oscar in the current manner

.

Applicable Membership

26

Authorization is currently required for Oscar Insurance members

enrolled in New York, New Jersey, Texas, Ohio and Tennessee. Newly

expanded to Arizona and Florida as of 1/1/2019.

Process

27

• There may be a circumstance where you have utilized the web portal to request a provider

authorization and received the message “ member not found”.

• If this occurs, please contact eviCore by phone at 1-855-252-1118.

• You will be connected with an agent who will ask for the information required for the Prior

Authorization request.

• The agent will execute on building a manual case for that member.

• The completed case will be sent to the eligibility team for verification of membership.

Member Not Found

28

Prior Authorization Required:

• Programs:

• Radiology

• Cardiology

• Lab Management

• Radiation Therapy

• Musculoskeletal(Chiropractic

and Pain Management)

• Sleep

• Medical Oncology

• Joint and Spine Surgery

• Specialty Drug

To verify all procedure codes requiring

prior authorization please refer to the

Oscar provider portal:

https://provider.hioscar.com

How to request prior authorization:

29

Prior Authorization Requests

Or by phone:

1-855-252-1118

7 a.m. to 7 p.m. (EST)

Monday - FridayWEB

www.eviCore.com

Available 24/7 and the quickest

way to create prior authorizations

and check existing case status

30

Clinical Review Process

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

31

Needed Information

MemberMember ID

Member name

Date of birth (DOB)

FacilityFacility name

National provider identifier (NPI)

Street address

Referring Physician

Physician name

National provider identifier (NPI)

Tax identification number (TIN)

Fax number

iRequests

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

• Therapy notes related to the current diagnosis

32

Prior Authorization Outcomes

• All requests are processed within 2 business days

after receipt of all clinical information.Approved Requests:

Delivery:

• Communication of denial determination.

• Communication of the rationale for the denial.

• How to request a Clinical Consultation.

• Faxed to the ordering provider and rendering

facility.

• Mailed to the member.

Delivery:

Denied Requests:

Delivery:

• Faxed to ordering provider and rendering facility.

• Mailed to the member.

• Information can be printed on demand by logging.

into eviCore healthcare portal.

33

Special Circumstances

Outpatient Urgent Studies:

Outpatient Urgent Studies:

Appeals:• eviCore healthcare will be delegated for first level

member and provider appeals.

• Requests for appeals must be submitted in writing to

eviCore within 180 days of the initial determination.

• A written notice of the appeal decision will be mailed

to the member and faxed to the provider.

• Medically urgent requests are defined as

conditions that are a risk to the patient’s life,

health, ability to regain maximum function, or the

patient is having severe pain that required a

medically urgent procedure.

• Contact eviCore by phone or use our online portal to

request an expedited prior authorization review and

provide clinical information.

• Urgent Cases will be reviewed within 72 hours of

the request.

• Verbal outreach is made to the ordering provider.

34

*New* Certification Summary

• CareCore National Portal now includes a Certification Summary

tab, to better track your recently submitted cases.

• The work list can also be filtered - as seen above.

Initiating A Case

35

Choose “request a clinical certification/procedure” to begin a new case request.

Select Program

36

Select the Program for your certification.

Select Provider

37

Select the Practitioner/Group for whom you want to build a case.

Select Health Plan

38

Choose the appropriate Health Plan for the case request. If the health plan does not

populate, please contact the plan at the number found on the member’s identification card.

Once the plan is chosen, please select the provider address in the next drop down box.

Contact Information

39

Enter the Provider’s name and appropriate information for the point of

contact individual.

Member Information

40

Enter the member information including the Patient ID number, date of birth, and

patient’s last name. Click “Eligibility Lookup.”

Clinical Details

41

Select the CPT and Diagnosis codes.

Verify Service Selection

42

Click continue to confirm your selection.

Site Selection

43

Select the specific site where the testing/treatment will be performed.

Site Selection

44

Confirm the site selection.

Clinical Certification

45

• 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.

Contact Information

46

Select an Urgency Indicator

and Upload your patient’s

relevant medical records that

support your request.

If your request is urgent select

No, if the case is standard

select Yes.

You can upload up to FIVE documents in .doc, .docx, or .pdf format. Your case

will only be considered Urgent if there is a successful upload.

Clinical Certification

47

Clinical Certification questions may populate based upon the information provided.

Clinical Certification

48

• You can click the “Finish Later” button to save your progress.

• You have two (2) business days to complete the case.

Clinical Certification

49

Select a reason for the requested study, or choose “Not Listed” if none of the

available options are appropriate.

Medical Review

50

If additional information is required, you will have the option to either free hand text in

the additional information box, or you can mark Yes to additional info and click submit

to bring you to the upload documentation page.

Providing clinical information via the web is the quickest, most efficient method.

Medical Review

51

If additional information is required, you will have the option to either free hand text in

the additional information box, or you can mark Yes to additional info and click submit

to bring you to the upload documentation page.

Providing clinical information via the web is the quickest, most efficient method.

Medical Review

52

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

Approval

53

Once the clinical pathway

questions are completed

and if the answers have met

the clinical criteria, an

approval will be issued.

Print the screen and store

in the patient’s file.

Building Additional Cases

54

Once a case has been submitted for clinical certification, you can return to the Main

Menu, resume an in-progress request, or start a new request. You can indicate if any

of the previous case information will be needed for the new request.

Authorization look up

55

• 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.

56

Search Results and Electronic Clinical Upload Feature

Eligibility Look Up

57

You may also confirm the patient’s eligibility by selecting the Eligibility Lookup tab.

58

Provider Resources

Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Pre-Certification Call Center

59

7:00 AM - 7:00 PM (Eastern Time): (855) 252-1118

• Clinically urgent requests

• 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

Quick Reference Tool

60

Access the Quick Reference Tool at www.evicore.com under the “Clinical Guidelines and

Forms” section.

Select Health Plan

Web Portal Services-Assistance-eviCore

61

Web Support

Phone: 800-646-0418 (Option 2)

Email: portal.support@evicore.com

Web Portal Services-Available 24/7

Pre-Certification

Call Center

Web-Based

Services

Client Provider

Operations

Documents

Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Client Provider Operations

62

clientservices@evicore.com

• Eligibility issues (member, rendering facility, and/or rendering

physician)

• Issues experienced during case creation

• Request for an authorization to be resent to the health plan

Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Implementation Document

63

Oscar Implementation site - includes program resources:

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

• Provider Orientation Training Presentations

• FAQ’s

• Link to Oscar website

• Clinical Guidelines

• Forms

• Provider Shortcuts

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

above

64

Thank You!