Sleep Solution for Harvard Pilgrim Health Care

Provider Training Program for Sleep ManagementPresented By:April Sabino

Sleep Disorders

Our Program:

1. NIA’s Sleep Solution

2. Prior-Authorization Program

3. Clinical Information Request and Review

4. Prior-Authorization Process

5. Notification of Determination

6. Network Approach

7. Provider Tools and Contact Information

Questions and Answers

NIA Program Agenda

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Sleep Disorders

Sleep Disorders can exacerbate medical issues resulting in increased healthcare utilization when left untreated

• Untreated sleep disorders can contribute to worsening of medical conditions such as heart disease, high blood pressure, diabetes, etc.

• The impact of sleep disorders is gaining wider recognition• Obstructive Sleep Apnea (OSA) affects 15 - 30 million people in the United

States and is the most prevalent sleep disorder• Other disorders include narcolepsy, periodic movement disorder, restless

leg syndrome, parasomnia, etc.

NIA ‘s Sleep Solution

• Addresses growing demand for sleep-related services

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NIA’s Sleep Solution for Harvard Pilgrim Healthcare

• Manages utilization of sleep tests‒ Ensures appropriate use of polysomnography based on clinical

guidelines‒ Reduces unnecessary repeat studies‒ Encourages sleep assessments when needed due to the potential for

other medical co-morbidities

• Promotes appropriate assessment setting‒ Supports facility-based testing when appropriate‒ Promotes the use of a Home Sleep Test (HST) for the assessment of OSA

when appropriate and HST is a benefit

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NIA Prior Authorization Program

• MRI/MRA• CT/CTA• PET• CCTA• Myocardial Perfusion Imaging• Stress Echo• Diagnostic Nuclear Medicine• Outpatient Interventional Pain Management – Spine• Inpatient or Outpatient Lumbar & Cervical Spine Surgeries

• Sleep Management –Commercial effective 9/1/17; StrideMedicare Advantage effective 1/1/18

• Sleep Assessment, unattended (Home Sleep Test) (CPT codes: 95800, 95801, 95806, G0398, G0399, G0400)

• Sleep Assessment, attended (CPT codes: 95805, 95807, 95808, 95810, 95811)

Procedures Requiring Prior Authorization

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Effective September 1, 2017 for Commercial membership and January 1st for Stride SM (HMO) Medicare Advantage membershipHarvard Pilgrim Health Care has partnered with NIA to expand the current Medical Specialty Management Program to include Sleep Solution services to provide the most appropriate assessment strategy for those with a suspected sleep disorder. NIA’s call center and RadMD will be available starting on August 28, 2017 for Commercial members and December 26, 2017 for Stride Medicare Advantage members.

Excluded from Program:Procedures Performed in the

Following Settings:

• Hospital Inpatient (except as noted above)• Observation• Emergency Room

List of CPT Procedure CodesRequiring Prior Authorization

• Review Claims/Utilization Review Matrix to determine CPT codes managed by NIA

• CPT Codes and their Allowable Billable Groupings

• Located on RadMD

• Defer to Harvard Pilgrim Health Care Policies for Procedures not on Claims/Utilization Review Matrix

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INSERT HEALTH PLAN SPECIFIC MATRIX SCREEN SHOT

Responsibility for Authorization

Ordering Provider

Responsible for obtaining prior authorization

Rendering Provider

Ensuring that prior authorization has been obtained prior to providing service

Recommendation to Rendering Providers: Do not schedule test until authorization is received

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Prior Authorization Process Overview

Ordering Physician

Telephone NIA Magellan’s Call

Center

Online Through RadMD

www.RadMD.com

Algorithm

Service AuthorizedRendering Provider

Performs ServiceClaim

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Prior Authorization Process Overview

Ordering Physician

Algorithm

Service AuthorizedRendering Provider

Performs ServiceClaim

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Submit Requests by Phone

Or Online Through RadMD

www.RadMD.com

Information evaluated via algorithm and medical records

Clinical Decision Making and Algorithms

• Guidelines are reviewed and mutually approved by Harvard Pilgrim Health Care and NIA Chief Medical Officers and guidelines are in sync with current Harvard Pilgrim Health Care policies today

• NIA algorithms and medical necessity reviews collect key clinical information to ensure that Harvard Pilgrim Health Care members are receiving appropriate care prior to procedures being performed. Our goal – ensure that Harvard Pilgrim Health Care members are receiving the appropriate assessment

• Clinical Guidelines available on www.RadMD.com

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Patient and Clinical Information Required for Authorization

GENERAL

Includes things like ordering physician information, Member information, rendering provider information, requested examination, etc.

CLINICAL INFORMATION• Clinical information needs to explain the

need for an attended sleep test, including:─ Patient symptoms, relevant patient

characteristics, patient’s current status and physical exam findings.

─ Screening test results or reports from other diagnostic tests; if request is due to a failed Home Sleep Test, include documentation of results and issues.

─ Contraindications to a Home Sleep Test, including the patient’s relevant medical history.

Refer to the Prior Authorization Checklists on RadMD for more specific information.

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Requesting Clinical Information

• NIA may request patient’s medical records/additional clinical information

• Providers may either submit medical records or contact our Nurse Reviewer with additional clinical information

• Medical records are preferred and are easy to upload via RadMD

• Helps ensure that patients receive the most appropriate, effective care

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NIA to Ordering Provider: Request for Additional Clinical Information

• A fax is sent to the provider requesting additional clinical information along with a Fax Coversheet for sending clinical records

• We stress the need to provide the clinical information as quickly as possible so we can make a determination

• Determination timeframe begins after receipt of clinical information

• Failure to receive requested clinical information may result in non certification

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Submitting Additional Clinical Information/Medical Records to NIA

• Ways to submit clinical information to NIA ‒ Medical Records via Fax or upload

on RadMD

‒ Phone call to a nurse reviewer via the call center at (800) 642-7543.

• Use the Fax Coversheet (when faxing clinical information to NIA)

• Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call Center @ (800) 642-7543, for your Harvard Pilgrim Health Care Members

Be sure to use the NIA Fax Coversheet for all transmissions of clinical information!

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Prior Authorization Process

Intake level Initial Clinical Review

• Requests are evaluated using our clinical algorithm

• Requests may:

1.Approve

2.Require additional clinical review

3.Pend for clinical validation of medical records

• Nurses will review request and may:

1.Approve

2.Send to NIA ‘s physician for additional clinical review*

• Physicians may:

1.Approve

2.Deny

Physician Clinical Review

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A peer to peer discussion is always available!

Notification of Determination

• Authorization Validity Period

• 30 days from DOS; If no DOS is given, authorization is valid 30 days from final determination date

• Denial Notification • Approval Notification

• Appeal Instructions

• In the event of a denial, providers may appeal the decision through Harvard Pilgrim Health Care

• Providers are asked to follow the appeal instructions provided in their denial letter

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• Harvard Pilgrim Health Care’s network of sleep assessment providers and facilities will be used

• Harvard Pilgrim Health Care’s Home Sleep Test providers are available when a HST is indicated; Home Sleep Tests (unattended sleep assessments) require prior authorization

Network Approach

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Provider Tools

• Toll free authorization and information number -(800) 642-7543 for your Harvard Pilgrim Health Care Members

• Available 8am-8pm EST

• Interactive Voice Response (IVR) System for authorization tracking

• RadMD Website – Available 24/7 (except during maintenance)

• Request authorization (ordering providers only) and view authorization status

• Upload additional clinical information

• View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents

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When to Contact NIA

Providers: Ordering Providers: To initiate a request for an authorization please contact NIA Call Center via toll-free number

(800-642-7543) or www.RadMD.com (NOTE: NIA does NOT accept faxes for the initiation of an authorization. Only via Call Center or RadMD website)

To check the status of an authorization please contact NIA Call Center via toll-free number (800-642-7543) or www.RadMD.com

Provider will be able to upload requested records on the NIA website www.RadMD.com or through the NIA fax number at (800-642-7543)

Sleep Assessment Providers and Facilities: To check the status of an authorization please contact NIA Call Center (800-642-7543) or

www.RadMD.com

Ordering Providers and Sleep Assessment Providers and Facilities: For assistance or technical support for RadMD, please contact RadMD Help Desk at 877-80-

RadMD (877-807-2363) or email RadMDSupport@MagellanHealth.com For any provider education requests specific to NIA and the Medical Specialty Solutions

Program, Providers may contact April Sabino, Provider Relations Manager (410-953-1078 or ajsabino@magellanhealth.com)

Confidentiality Statement for Educational Presentations

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By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

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