Sleep Solution for Coventry Health Care of Florida and Aetna Medicare HMO Members

Provider Training Program for Sleep Management Presented By:

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 Coventry of Florida & Aetna Medicare HMO • 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 ‒ Home Sleep Tests do not require prior authorization from

from NIA or Coventry Health Care of Florida/Aetna

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NIA Prior Authorization Program

• MRI/MRA • CT/CTA • PET • CCTA • Myocardial Perfusion Imaging • Stress Echo • Diagnostic Nuclear Medicine NEW • Sleep Management –Commercial and Medicare

effective August 1, 2016 • Sleep Assessment, attended (CPT codes:

95805, 95807, 95808, 95810, 95811, 95782, 95783)

Procedures Requiring Prior Authorization

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Effective August 1, 2016 Coventry Health Care of Florida and Aetna have partnered with NIA to expand the current Radiology Management Program to include Sleep Solution services to provide the most

appropriate assessment strategy for those with a suspected sleep disorders.

Excluded from Program: Procedures Performed in the

Following Settings:

• Hospital Inpatient • Observation • Emergency Room

List of CPT Procedure Codes Requiring 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 Health Plan Policies for Procedures not on Claims/Utilization Review Matrix

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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 Authorized Rendering Provider

Performs Service Claim

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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 Coventry Health Care of Florida/Aetna and NIA Chief Medical Officers and guidelines are in sync with current Coventry Health Care of Florida/Aetna polices today

• NIA algorithms and medical necessity reviews collect key clinical information to ensure that Coventry Health Care of Florida and Aetna Medicare HMO members are receiving appropriate care prior to procedures being performed. Our goal – ensure that Coventry Health Care of Florida and Aetna Medicare HMO 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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Document Review

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

• When requested, validation of clinical criteria within the patient’s medical records is required before an approval can be made

• Ensures that clinical criteria that supports the requested test are clearly documented in medical records

• 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 medical records, along with a Fax Coversheet

• 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

• Two ways to submit clinical information to NIA

‒ Via Fax

‒ Via RadMD Upload

• 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) 642-7821 or (800) 424-1727, for your Aetna Medicare HMO 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

• 90 days from call in date.

• Denial Notification

• Approval Notification

• Appeal Instructions

• In the event of a denial, providers may appeal the decision through Coventry Health Care of Florida/Aetna

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

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• Coventry Health Care of Florida and Aetna’s network of sleep assessment providers and facilities will be used

• Coventry Health Care of Florida and Aetna’s Home Sleep Test providers are available when a HST is indicated; Home Sleep Tests (unattended sleep assessments) do not require prior authorization.

Network Approach

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Provider Tools

• Toll free authorization and information number - (800) 642-7821 or (800) 424-1727, for your Aetna Medicare HMO 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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Dedicated Provider Relations Contact Information

NIA Dedicated Provider Relations Manager :

Name : Humberto Hernandez

Phone: 1-800-450-7281, ext. 53682

Email: HHernandez@magellanhealth.com

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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. The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment. The information contained in this presentation is intended for educational purposes only and should not be considered legal advice. Recipients are encouraged to obtain legal guidance from their own legal advisors.

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