Radiology & Cardiology Prior Authorization Provider Education · Provider Responsibilities -...

Radiology & Cardiology Prior AuthorizationProvider EducationJune 2013

Agenda

• Prior Authorization Overview

• Radiology/Cardiology Protocol Changes

• Prior Authorization Requirement & Process

• Notification/Prior Authorization Retrospective Comparison Grid

• Resources/Reference Materials

• Q&A

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Doc#: UHC2584a_20130617 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Overview

Promoting the delivery of the right care, at the right time, in the right setting.

• Benefits:

• Continued support to physicians in their decision-making process

• Enhance consistency between use of advanced imaging and cardiologyprocedures and current scientific clinical evidence and professional society guidance

• Demonstrate appropriateness of procedures prior to being rendered.

• Identify and avoid duplication of advanced outpatient imaging procedures and cardiology diagnostic studies

• Reduce unnecessary radiation exposure to our members

• Mitigate medical cost trend by addressing variations in quality, safety and appropriateness

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• How is it different from UnitedHealthcare’s existing process?

• Coverage determinations will be based upon clinical reviews that utilize medical necessity criteria.

• If the requested service does not meet medical necessity criteria, a clinical denial will be issued and the member and provider will receive a denial notice with the option to initiate an appeal.

• Services rendered that are deemed NOT medically necessary during pre-service review will not be covered. Members may choose to move forward with service which will result in member liability if the provider obtains adequate written consent from the member before services are rendered.

Member visits a physician for

care and physician

recommends a test, procedure or a service that

requires prior authorization

Physician or facility contacts

UnitedHealthcare to inform

UnitedHealthcare of the proposed

service.

UnitedHealthcare reviews the

request to verify the service

is a covered benefit and is

medically necessary.

A determination is rendered.

Physician and member review determination

letter and plan a course of care.

Claim is submitted for

service rendered.

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• How does prior authorization work?

Overview


• Effective July 1, 2013, UnitedHealthcare is changing its existing Outpatient Radiology Notification Protocol and Cardiology Notification Protocol to include a prior authorization requirement.

• Also effective July 1, 2013, UnitedHealthcare is changing the scope of its existing Outpatient Radiology and Cardiology Prior Authorization programs in place for select Commercial, Medicare Advantage and Community Plan members:

• Medicare Advantage – Radiology and Cardiology Prior Authorization expansion to ID, NE, OR, WA

• UnitedHealthcare Community Plan – Radiology Prior Authorization expansion to WA; Cardiology Prior Authorization deployment to MD & WA (7/1); NE & TN (7/15)

• Oxford Health Plans – Cardiology Prior Authorization deployment (cardiac catheterizations only)

• River Valley – Cardiology Prior Authorization procedure expansion to include echocardiograms and stress echocardiograms

• Neighborhood Health Partnership – Cardiology Prior Authorization procedure expansion to include echocardiograms; transition of stress echocardiograms from Radiology Prior Authorization to Cardiology Prior Authorization process

• Effective August 5, 2013, UnitedHealthcare is expanding its existing Radiology Prior Authorization Program and adding a Cardiology Prior Authorization Program for Community Plan members in TX.

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Protocol Changes


• Prior authorization requirement:

• Prior authorization is required if a UnitedHealthcare commercial member’s benefit document requires that services be medically necessary to be covered.

• If prior authorization is required, a clinical coverage review will be conducted to determine if the service is medically necessary based on evidence-based clinical guidelines, once notification of a planned service is received.

• Providers do NOT need to determine whether a clinical coverage review is required in a given case or for a given member as UnitedHealthcare will let the provider know whether a clinical coverage review is required.

• If the member’s benefit document does not require clinical coverage review to determine medical necessity, and if the service does not meet evidence-based clinical guidelines, or if additional information is needed, UnitedHealthcare will confirm whether the provider must engage in a physician-to-physician discussion.

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Requirement and Process


• Imaging modalities:

• The list of advanced imaging procedures requiring prior authorization is the same as the list of procedures requiring advance notification (certain CT scans, MRI/MRAs, PET scans, nuclear medicine and nuclear cardiology studies).

• The advanced imaging procedures for which authorization is required are referred to as “Advanced Outpatient Imaging Procedures.”

• Places of service:

• Required: Outpatient hospital locations, freestanding imaging centers and physicians’ offices.

• Not required: Emergency room, urgent care center, observation unit or during an inpatient stay.

• Request process:

• Initiate the notification process by phone or online.

• Evidence-based clinical guidelines:

• The evidence-based clinical guidelines used to determine medical necessity for prior authorization is the same as the guidelines for advance notification.

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Radiology Requirement


• Cardiology procedures:

• The list of procedures requiring prior authorization is the same as the list of procedures requiring advance notification (cardiac catheterizations and electrophysiology implants).

• Echocardiograms and stress echocardiograms will require prior authorization effective July 1, 2013 (except when rendered in an emergency room, urgent care facility or during an inpatient stay).

• Places of service:

• Echocardiograms, stress echocardiograms and cardiac catheterizations performed in outpatient settings.

• Electrophysiology implants in both the inpatient and outpatient settings.

• Request process:

• Initiate the notification process by phone or online.

• Evidence-based clinical guidelines:

• The evidence-based clinical guidelines used to determine medical necessity for prior authorization are the same as the guidelines for advance notification.

Cardiology Requirement


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• Ordering provider’s responsibilities:

• The ordering provider’s office requesting the imaging service is responsible for obtaining a prior authorization number before scheduling the advanced outpatient imaging procedure.

• Rendering provider’s responsibilities:

• Rendering providers must confirm that the notification/prior authorization process has been completed and a coverage decision has been issued by contacting UnitedHealthcare before rendering the advanced outpatient imaging procedure.

• If the notification/prior authorization process has not been completed, contact the ordering provider. The ordering provider must obtain the authorization as they have the necessary clinical information for the medical necessity review.

• If the ordering provider does not participate in UnitedHealthcare’s network or is unwilling to complete the prior authorization process, the rendering provider must complete the prior authorization process and verify that a coverage decision has been issued prior to rendering the service.

• To initiate the process or confirm that a coverage determination has been issued:

• UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Radiology Notification & Authorization - Submission & Status OR

• Telephone: 866-889-8054 (7 a.m. to 7 p.m. local time, Monday - Friday)

Provider Responsibilities - Radiology


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• Ordering provider’s responsibilities:

• The ordering provider’s office requesting the cardiology service is responsible for notifying UnitedHealthcare prior to scheduling the service.

• Rendering provider’s responsibilities:

• Rendering providers must confirm that the notification/prior authorization process has been completed and a coverage decision has been issued by contacting UnitedHealthcare before rendering the service.

• If the rendering provider determines the notification/prior authorization process has not been completed and a coverage determination has not been issued if required, contact the ordering provider. The ordering provider must obtain the authorization as they have the necessary clinical information for the medical necessity review.

• If the ordering provider does not participate in UnitedHealthcare’s network or is unwilling to complete the prior authorization process, the rendering provider must complete the prior authorization process and verify that a coverage decision has been issued prior to rendering the service.

• To initiate the process or confirm that a coverage determination has been issued:

• UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Cardiology Notification & Authorization - Submission & Status OR

• Telephone: 866-889-8054 (7 a.m. to 7 p.m. local time, Monday - Friday)

Provider Responsibilities - Cardiology


• The provider who notifies UnitedHealthcare of the planned advanced outpatient imaging procedure or cardiology procedure will be informed of the decision.

• An authorization number will be issued for procedures consistent with evidence-based clinical guidelines.

• An authorization number will not be issued for procedures that are not consistent with evidence-based clinical guidelines and the claim for the service will be denied for lack of medically necessity.

• If the clinical information submitted is insufficient to determine whether the service is medically necessary, a letter will be sent to the provider requesting additional information.

• If additional information is provided within 45 days, a clinical coverage review will be conducted to determine whether the service is medically necessary.

• If additional information is not provided within 45 days, the request for authorization will be denied, and if the service is rendered, the claim for the service will be denied for lack of medical necessity.

*45-day timeframe is for UnitedHealthcare’s Commercial benefit plans and products; **Medicare Advantage and Community Plan timeframe is 14 days.

Clinical Coverage Review Process


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• Clinical coverage review process (cont.):

• If the requested service does not meet medical necessity criteria, a clinical denial will be issued and the member and provider will receive a denial notice with the option to initiate an appeal.

• Failure to meet medical necessity criteria:

• A clinical denial will be issued if it is determined that the requested service does not meet medical necessity criteria.

• Members can be billed for claims that are clinically denied provided adequate written consent is obtained from the member.

• Failure to complete the process:

• Failure to provide notification and complete the prior authorization process, or verify that a coverage determination has been issued, prior to rendering a procedure subject to the radiology or cardiology notification protocols will result in an administrative claim reimbursement reduction, in part or in full.

• Providers cannot balance bill members for claims that are administratively denied.

Clinical Coverage Review Process


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• Case Number:

• A 10-digit case number is assigned for each prior authorization case (e.g. 1003456789).

• When a request cannot be completed after it is initiated, the case number is used as a reference tool and to promote administrative efficiency in completing the case (e.g. access case details during a physician-to-physician discussion).

• Case numbers are not valid for claim payment.

• Notification Number:

• If prior authorization is not required, and the procedure is consistent with evidence-based clinical guidelines, a notification number will be issued.

• Notification numbers are alpha/numeric; the format is the letters “CC” followed by an 8-digit number and the CPT code (e.g. CC12345678-78452).

• Authorization Number:

• If prior authorization is required, and the procedure is consistent with evidence-based clinical guidelines, an authorization number will be issued.

• Authorization numbers are alpha/numeric; the format is the letter “A” followed by a 9-digit number (e.g. A012345678).

Notification/Authorization Numbers


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Notification/Prior Authorization Radiology Comparison Grid

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Key Points Current Outpatient Radiology Protocol

Outpatient Radiology Protocol With a Prior Authorization Requirement

Global and Technical claims are subject to administrative denial for failure to complete the notification/prior authorization process.

Which claims are subject to administrative denial?

GlobalTechnical (TC)

GlobalTechnical (TC)

Administrative denial remark codes

Claims administratively denied for failure to complete the notification process are identified using remark code “VP.”

Claims administratively denied for failure to complete the prior authorization process are identified using remark code “BT.”

Medical necessity denials Not applicable Global, Technical and Professional claims are subject to denial for lack of medical necessity.

Which claims are subject to denial for lack of medical necessity?

Not applicable Administrative denials

Medical necessity denial remark codes

Not applicable Claims that are denied for lack of medical necessity are identified using remark code “6A” (provider liability) or 6B (member liability).

Under what scenarios may the provider bill the member?

Members cannot be billed for claims that have been administratively denied.

Members cannot be billed for claims that have been administratively denied.Members can be billed for claims that are denied for lack of medical necessity if the provider obtains adequate written consent from the member before the service is rendered.


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Key Points Current OutpatientRadiology Protocol

Outpatient Radiology Protocol Witha Prior Authorization Requirement

What is the impact to hospital-based physicians (HBP)?

Professional claims are not subject to administrative denial for failure to provide notification.

Professional claims are not subject to administrative denial for failure to provide notification.Professional claims are subject to clinical denial for lack of medical necessity.

What is the impact to non-participating ordering providers?

Non-par ordering providers can provide notification/request prior authorization.However, if the notification/prior authorization process has not been completed, and the non-participating ordering provider is unwilling to complete the process, the rendering provider is required to complete the process.

Guarantee of payment Subject to state regulation, receipt of a notification/prior authorization number does not guarantee or authorize payment. Payment of the covered services is contingent upon several factors, including the member’s eligibility on the date of service, the terms of the provider’s participation agreement and UnitedHealthcare’s reimbursement policies.

Notification/Prior Auth. number on claim form

There is no need to include the prior authorization/notification number on the claim form; however the provider may do so at their discretion.

Secondary Plan Notification/prior authorization is not required when UnitedHealthcare is the secondary coverage to any other payer, including Medicare.

Questions about eligibility, benefits & claims

Call 877-842-3210, then using voice recognition identify either “Claims” for claims payment and appeals or “Benefits and eligibility” to: check if the service requires notification/prior authorization, check member eligibility or for miscellaneous provider/benefit questions.

Notification/Prior Authorization Radiology Comparison Grid


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Key Points Current Cardiology Protocol Cardiology Protocol With a Prior Authorization Requirement

Places of service/procedures

All places of service for cardiac catheterizations and electrophysiology implants

Outpatient places of service for cardiac catheterization, echocardiograms and stress echocardiograms. Both inpatient and outpatient for electrophysiology implants.

Which claims are subject to administrative denial?

All physician claims Global and technical for echocardiograms and stress echocardiograms, all HCFA and UB04 claims for catheterizations and electrophysiology implants

Administrative denial remark codes

Claims administratively denied for failure to complete the notification process are identified using remark code “CD.”

Claims administratively denied for failure to complete the prior authorization process are identified using remark code “NU.”

Medical necessity denials Not applicable All HCFA and UB04 Claims

Which claims are subject to denial for lack of medical necessity?

Not applicable All HCFA and UB04 Claims

Medical necessity denial remark codes

Not applicable Claims that are denied for lack of medical necessity are identified using remark code “6A” (provider liability) or 6B (member liability).

Under what scenarios may the provider bill the member?

Members cannot be billed for claims that have been administratively denied.

Members cannot be billed for claims that have been administratively denied.Members can be billed for claims that are denied for lack of medical necessity if the provider obtains adequate written consent from the member before the service is rendered.

Notification/Prior Authorization Cardiology Comparison Grid


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Key Points Current Cardiology Protocol Cardiology Protocol With a Prior Authorization Requirement

What is the impact to hospital-based physicians (HBP)?

All HCFA Claims subject to denial for lack of notification

Professional claims are not subject to administrative denial for failure to provide notification for echocardiogram and stress echocardiograms ONLY.All professional claims are subject to clinical denial for lack of medical necessity.

What is the impact to non- participating ordering providers?

Non-par ordering providers can provide notification/request prior authorization.However, if the notification/prior authorization process has not been completed, and the non-participating ordering provider is unwilling to complete the process, the rendering provider is required to complete the process.

Guarantee of payment Subject to state regulation, receipt of a notification/prior authorization number does not guarantee or authorize payment. Payment of the covered services is contingent upon several factors, including the member’s eligibility on the date of service, the terms of the provider’s participation agreement and UnitedHealthcare’s reimbursement policies.

Notification/Prior Auth. number on claim form

There is no need to include the prior authorization/notification number on the claim form; however the provider may do so at their discretion.

Secondary Plan Notification/prior authorization is not required when UnitedHealthcare is the secondary coverage to any other payer, including Medicare.

Questions about eligibility, benefits & claims

Call 877-842-3210, then using voice recognition identify either “Claims” for claims payment and appeals or “Benefits and eligibility” to: check if the service requires notification/prior authorization, check member eligibility or for miscellaneous provider/benefit questions.

Notification/Prior Authorization Cardiology Comparison Grid


Clinical Review Timeframes

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• Scheduling procedures and imaging studies as far in advance as possible is highly recommended.

• If additional information is required, response times may vary depending on the line of business and the program, for example:

• Standard requests will have a decision rendered in two business days of receipt of all information.

• Urgent requests will have a decision rendered within three hours of receipt of information.

• If additional information is required before a decision can be rendered, providers have 45 calendar days to submit the requested information. (For Medicare Advantage and Community Plan, providers will have 14 days.)

• Authorizations are valid for 45 days from issuance.

Retrospective Process and Timeframes

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Notification/Prior Authorization Retrospective Days Allowed for Cases Cardiology (Urgent – After Hours) Radiology (Urgent - After Hours)

Diagnostic Catheterizations & Electrophysiology Implants

StressEchocardiography/ Echocardiography

Advanced Outpatient Imaging Procedures

Commercial Notification

30 days (Applies to Urgent –After Hours & services performed during inpatient stays)

N/A 2 business days

Commercial Prior Authorization

15 days 2 business days 2 business days

Medicare Advantage Prior Authorization


Community Plan Prior Authorization


Neighborhood Health Partnership Precertification (referred to as “Late Precertification")


UnitedHealthcare of the River Valley Prior Authorization

15 days 2 business days N/A

Oxford Health Plans Prior Authorization

• 15 days for diagnostic catheterization • All other procedures: 2 business days 2 business days

*Days are calendar days unless otherwise indicated.


Tools & Resources

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• For your reference, this information is available at:

• UnitedHealthcareOnline.com > Clinician Resources > Radiology > Radiology Notification/Authorization

• UnitedHealthcareOnline.com > Clinician Resources > Cardiology >Cardiology Notification/Prior Authorization Program

• Resource materials include:

• Frequently Asked Questions

• Quick Reference Guides

• Evidence-based Clinical Guidelines

• Notification/Prior Authorization CPT Code List

• Notification/Prior Authorization Crosswalk Table

• Modality-specific Information Worksheets

• and more!


Q&A

Questions?

21Doc#: UHC2584a_20130617 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Appendix

• Medical Necessity Overview

• Evidence-based Clinical Guidelines

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Medical Necessity Overview

• Medical Necessity will help drive optimal patient outcomes

• Advance consistent, quality care by applying Medical Necessity criteria based on the best-available clinical science.

• Improve heath care quality by raising performance and reducing variation in medical practice.

• Reduce unnecessary risk to members by promoting adherence to evidence-based guidelines.

• Medical Necessity will help make care more affordable

• Mitigate medical cost trend and address variation in the quality, safety and utilization.

• Allow care to be delivered appropriately and efficiently based on the best clinical practices developed by the medical community, which results in more affordable care.

• Medical Necessity will help drive administrative simplification

• Deploying Medical Necessity establishes consistent and streamlined procedures for our provider network.

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Clinical Appropriateness

Clinical Effectiveness

Cost Effectiveness

Clinical Evidence

• Clinical evidence

• Credible, published, scientific evidence supported by controlled clinical trials or observational studies.

• Rigorous and consistent clinical management of:

• Clinical effectiveness - Treatment of illness, injury, disease or symptom must be proven to be clinically effective.

• Clinical appropriateness - Type, frequency, extent and duration of services must be appropriate for the individual member.

• Cost effectiveness - Services must not be more costly than alternative services that are at least as likely to produce equivalent therapeutic and diagnostic results.

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Medical Necessity Overview


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• Requires migration to the 2011 COC or SPD that supports medical necessity as a requisite for benefit coverage

• Medical necessity determination applied to a service

• All services on our Prior Authorization list are subject to the appropriate evidence-based review

• Based on our facility contracts

• Bed days or levels of care determined to be not medically necessary are facility liability; member is held harmless

• Member must be on a COC/SPD that supports such review

Evidence-based Medicine Clinical Appropriateness

Clinical EffectivenessCost Effectiveness

Inpatient Care ManagementConcurrent or retrospective reimbursement

decision for inpatient bed days

Prior AuthorizationPre-service benefit coverage decision

for a service, procedure or test

Radiology and Cardiology Prior AuthorizationPre-service benefit coverage decision

for a service, procedure or test

• In effect for fully insured plans on the 2011 COC beginning 7/1/2013

• Available for ASO plans on an SPD supporting medical necessity beginning 1/1/2014

Medical Necessity Model Components


Clinical Guidelines

• Evidence-based clinical guidelines are:

• Developed by a committee of practicing academic- and community-based radiologists and specialty consultants.

• Based on guidelines and standards published by nationally and internationally recognized medical societies, supplemented by material from peer-reviewed literature.

• Reviewed by the Guideline Review Committee, which meets every other month to examine and modify select guidelines as necessary to reflect the most current evidence-based clinical guidelines for imaging and cardiology.

• All clinical guidelines are reviewed at least annually.

• Fully transparent to the provider and posted on UnitedHealthcareOnline.com.

• Evidence-based clinical guidelines used for our Medicare Advantage plans also include Medicare’s local and national coverage determinations.

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To access these guidelines, please go to UnitedHealthcareOnline.com:Clinician Resources > Radiology > Radiology Notification/Prior Authorization > Resources: Reference Materials ORClinician Resources > Cardiology > Cardiology Notification/Prior Authorization Program > Important Program Information


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