Radiology Benefit Management Program Provider Training June 2009

Magellan Health Services, Inc. | 2 Provider Training Program Agenda  Welcome and Opening Remarks  CareSource’s Implementation of a Radiology Benefit Management (RBM) Program  About NIA  The Provider Partnership  The Provider Assessment Program  How the Program Works:  The Authorization Process  The Authorization Appeals Process  The Claims Process  The Claims Appeals Process  Provider Self-Service Tools (RadMD and IVR)  RadMD Demo  Provider Communication and Service as High Priority  NIA Provider Relations and Contact Information  Questions and Answers

Magellan Health Services, Inc. | 3 Why a Radiology Benefit Management Program for CareSource?  QUALITY OF CARE:  Through ongoing utilization and quality monitoring, CareSource identified trends that indicated the need for further analysis of the radiology procedures being provided to CareSource members.  PATIENT SAFETY:  Clinical literature demonstrates that many high-tech radiology exams are performed when there is not a clinical indication that the test will alter diagnostic certainty. Therefore, patients are needlessly exposed to radiation and health care costs are wastefully consumed.  VALUE :  To appropriately manage the increasing utilization of these services so as to avoid:  The use of resources without benefit to the patients that the system is intended to help.  Unsustainable cost trends, image quality issues, and safety concerns. CareSource elected to implement a Radiology Benefit Management Program, in partnership with NIA, to ensure:

Magellan Health Services, Inc. | 4 Clinical Data Review  Patient Safety  Each CT study (3 or more scans) will provide about 50 millisieverts (msv) of exposure depending on various factors.  Large-scale studies of radiation related workers demonstrate significant increased risk of cancer for those exposed to more than 150 msv; with children being at greater risk than adults.  The current estimate for incidence of cancer due directly to CT radiation exposure is % of all cancers in the U.S.

Magellan Health Services, Inc. | 5 Clinical Data Review (continued)  The American College of Radiology published an article, later referenced in a story in the Cleveland Plain Dealer. The data represented 115% increase in CT scans performed in the U.S. between 1998 and 2005 and a 383% spike in office CT scans performed by non-radiologists. Ohio data showed a 117% increase overall and 3,954% increase in office CT scans performed by non-radiologists.  For a 2-year period between May 2005 and April 2007, Caresource experienced a 20% year-over-year trend for CT scans alone.  Because of poor continuity of care, lack of medical home, drug seeking behavior and other factors many CareSource members have had far in excess of three (3) CT studies and increased radiation risk, suggesting patient safety issues that need to be managed.

Magellan Health Services, Inc. | 6 About NIA National Imaging Associates (NIA) -- chosen as the solution for National and Regional Health Plans covering more than 18 million lives due to:  Distinctive clinical focus.  Accredited by NCQA and URAC-certified.  Innovation and Stability -- Parent is Magellan Health Services -- enhances operational competencies, IT capabilities and patient support tools; affords financial stability for growth and continued investment in innovative technology.  Operating in Ohio since 2001 – Solid Experience in Working with the Ohio Health Care Community. Focus / Results: Maximizing diagnostic services value; promoting patient safety through:  A clinically-driven process that safeguards appropriate diagnostic treatment for CareSource beneficiaries.  Convenient access to a network of qualified providers.  Identification of patient-specific convenience items to support unique member needs. NIA is accredited by NCQA and URAC

Magellan Health Services, Inc. | 7 The NIA Provider Partnership Model  Process of Ensuring Quality Services  NIA’s privileging programs ensure that high-quality facilities—meeting rigorous credentialing criteria—deliver services to members.  Dedication to Provider Service and Convenience  Provider Call Center  Dedicated PR staff  Authorization Call Center  Interactive Voice Response (IVR)  Innovative Provider Tool – RadMD  Education and Training Programming  Ongoing Outreach to Providers – ordering provider surveys, individual ordering / rendering practice retraining, satisfaction surveys, etc.  Provider Newsletters

The Provider Assessment Process for Rendering Providers

Magellan Health Services, Inc. | 9 NIA’s Provider Assessment Program  NIA has a Comprehensive Program for Evaluating Imaging Providers Selected to Participate in the CareSource Radiology Benefit Management Program  The NIA Provider Assessment Program encompasses:  Both Credentialing and Privileging into the selection process.  Reviews both free-standing facilities (FSF) and radiologists.  NIA’s Credentialing Program  Focuses on NIA contracted providers – FSFs and radiologists.  Applies a rigorous set of standards to ensure quality and competency.  NIA’s Network and Credentialing Committee makes decisions about participation status.

How the Program Works: -- The Authorization Process -- The Claims Process -- Provider Appeals

Magellan Health Services, Inc. | 11  Utilization Management/Authorizations: NIA's proprietary, evidence-based decision support algorithms support scripting for call center representatives or online - leading to quick procedure approval or consultation with our radiology experts.  Information and Transaction Tools: RadMD.com Web site provides the ability for ordering providers to request and obtain authorizations, reference lists of nearby imaging facilities, locate authorizations given, gain rapid authorization requests. Providers report a high level of satisfaction with their use of RadMD finding it a simple tool to use and a time-saver for staff.  Ordering Provider Program: Analyze referral patterns with CareSource and develop additional education and outreach opportunities to the provider community to review various facility options based upon convenience factors for members (i.e., free parking, on a public transportation line, weekend hours, etc.). Program Components

Magellan Health Services, Inc. | 12 Facility Selection Goals  The facility selection process is based on quality of care, patient support and cost effectiveness: - Always considers the clinical aspect of the patient when making facility recommendations - Helps ensure that patients go to quality imaging facilities with convenient services that meet their needs. - Facilitates the delivery of tests at free-standing, outpatient facilities (when appropriate) to support lower costs  The more the ordering physician knows about their patient’s unique needs, the better the experience can be customized to the patient  With this additional support, the patient is more likely to have the ordered test

Magellan Health Services, Inc. | 13 How Facilities are Selected  During prior authorization, the authorization representative will help the ordering provider select a facility based on:  Clinical requirements (driven by type of test, patient need)  Patient zip code  Patient convenience services  Cost effectiveness  Prior authorization will be tied to a specific facility Search narrowed to facilities that perform requested test within zip code Search narrowed to facilities with identified convenience services within the selected zip code Facility Selected All available facilities that meet approved facility requirements for indicated test

Magellan Health Services, Inc. | 14 Convenient Services that can be Selected  Transportation and parking - Public transportation accessibility - Free parking  Language Assistance - Languages spoken by office staff - Telecommunication equipment for deaf patients  Weekend or Evening Hours - Extended evening hours - Weekend hours  Childcare - Onsite availability of someone to watch child - Onsite child play area

The Authorization Process

Magellan Health Services, Inc. | 16 Prior Authorization is required for:  Non-Emergent Outpatient:  CT  MRI/MRA  PET Scan  No Prior Authorization is required for:  Inpatient CT, MRI/MRA/MRS, PET Scan  Hospital Observation CT, MRI/MRA/MRS, PET Scan  Emergency Room CT, MRI/MRA/MRS, PET Scan

Magellan Health Services, Inc. | 17 Clinical Validity of Algorithms  NIA currently reviews more than 450,000 advanced imaging requests each month.  Algorithms and guidelines are reviewed and approved by CareSource Medical Directors.  Many of our current algorithms recommend the substitution of more costly but more effective imaging technology. Our goal is to suggest the most appropriate test early in an episode of care.  Consultative communication is a hallmark of NIA – NIA has a team of 62 board-certified physicians representing radiology and a host of other specialties available for physician to physician discussions.

Magellan Health Services, Inc. | 18  The ordering physician is responsible for obtaining prior authorization.  The rendering provider must ensure that prior authorization has been obtained and it is recommended that you not schedule procedures without prior authorization.  Procedures performed without proper authorization will not be reimbursed.  If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed, either the radiologist or rendering provider should proceed with the additional study and contact NIA within one (1) business day to initiate the review process for medical necessity.  If an urgent clinical situation exists outside of a hospital emergency room, the radiologist or rendering provider should proceed with the study and contact NIA the next business day to go through the normal review process.  Separate pre-certification numbers are not needed for CT-guided biopsy, CT-guided radiation therapy and some MR-guided procedures. NIA’s Authorization Process

Magellan Health Services, Inc. | 19 x NIA Prior Authorization Process Physician’s office contacts NIA for prior consultation via web or telephone 100% cases Procedure is approved by agent ~60% cases Case is transferred to nurse for review ~40% cases Procedure is approved by nurse ~20% cases Case is transferred to physician for review ~20% cases Procedure is approved by a physician reviewer ~10% cases Procedure is denied by a physician reviewer ~5% cases Case is withdrawn by the ordering physician ~5% cases  Agent LevelNurse Level ?  ? Physician Level  x Call time of approximately 5 minutes On average, 92% of all cases receive final determinations within hours

Magellan Health Services, Inc. | 20 Authorization Process and Components (Annual Statistics) 173 Customer Service Associates 68 staff in support roles 56 Initial Clinical Review staff (RN, LPNs, RT) 34 staff in support roles 62 Board certified Physician Clinical Reviewers Inbound calls 3,043,342 RadMD Authorizations 1,015,432 Case Reviews 1,461,386 Case Reviews 547,629 Activity Staff Clinical ICR Clinical PCR Intake Call

The Authorization Appeals Process

Magellan Health Services, Inc. | 22 The Authorization Appeals Process In the event of a denial and you are not satisfied with a medical decision, you may appeal the decision through CareSource. You will receive appeal information in the denial letter that will be sent to you.

The Claims Process

Magellan Health Services, Inc. | 24 How Claims Should be Submitted  Rendering providers/Imaging providers should continue to send their claims directly to CareSource at: CareSource P.O. Box 8730 Dayton, OH  Providers are strongly encouraged to use EDI claims submission with CareSource Payer Identification number:  Check on claims status by logging on to the CareSource website --

The Claims Appeals Process

Magellan Health Services, Inc. | 26 The Claims Appeals Process In the event of a claims payment denial, you may appeal the decision through CareSource. Send your claim appeal letter with supporting documentation to: CareSource Attn: Appeals P.O. Box 2008 Dayton, OH

Self Service Tools and Usage

Magellan Health Services, Inc. | 28 Multi-Channel Provider Relations Strategy Radiology Provider Interactive Voice Response RadMD.com / MagellanHealth.com High Touch Internet Offerings Member Eligibility Secure Messaging Provider Data Change Form Credentialing Initiate Authorization (Ordering Provider) Authorization Inquiry Provider Service Line & Provider Relations Staff Provider Support & Inquiries Provider Forums/Education Centralized and Regional Support IVR – Interactive Voice Response Member Eligibility Authorization Inquiry

RadMD Demo

Magellan Health Services, Inc. | 30 Self Service Tools and Usage Interactive Voice Response (IVR)  Use tracking number to check status of cases. Website:  Use tracking number to review an exam request.

Magellan Health Services, Inc. | 31  Information concerning approved authorizations can be viewed at after login with username and password.  Providers may search based on the patient’s ID number, name or authorization number. NIA Website --

Magellan Health Services, Inc. | 32  Provide you with instant access to much of the high tech imaging prior authorization information that our call center staff provides, but in an easily accessible Internet format.  We encourage all ordering providers to submit all requests on line.  With RadMD, the majority of cases will be authorized online with ease; however, we will resolve pended cases through our Clinical Review department.  Website can provide you with up-to-the-hour information member authorizations, including date initiated, date approved, exam category, valid billing codes and much more. NIA Website – Ordering Providers

Magellan Health Services, Inc. | 33  User-friendly, near-real-time Internet tool offered by NIA.  Available from 5:00 a.m. to 12:00 a.m. EST Monday – Friday; Saturdays from 8:00 a.m. to 1:00 p.m. EST  Log on to RadMD  RadMD.com website can offer providers direct access to:  Members’ authorizations  Date initiated  Exam requested  Valid billing codes (CPT)  Secure messaging  Ease of updating practice information under My Profile  Current provider news  Access to a full range of helpful content including our Imaging Provider Handbook, Diagnostic Imaging Guidelines, Quick Reference Guide NIA Website - Imaging Facilities

Magellan Health Services, Inc. | 34  Click the “New User” button on the right side of the home page.  Fill out the application and click the “Submit” button.  You must include your address in order for our Webmaster to respond to you with your NIA-approved user name and password.  Everyone in your organization is required to have his or her own separate user name and password due to HIPAA regulations.  On subsequent visits to the site, click the “Login” button to proceed. To get started, visit

Magellan Health Services, Inc. | 35 NIA Provider RadMD User Survey Findings Q: What are the most notable characteristics of this tool? Common Themes:  “Enjoy using RadMD because it saves time and is user-friendly.”  “To the point, no long detailed explanations” or “repeat questions”.  “Provides immediate status of authorizations.”  “Don’t have to tie up phone lines.”

NIA Provider Relations

Magellan Health Services, Inc. | 37 Provider Relations Structure and Portals  Dedicated provider service line for provider inquiries  Radiology Network Services line at  Dedicated NIA Provider Relations Manager for CareSource Providers -- Stephanie Martin who will be there for you to :  Educate Ordering and Rendering Providers as to how the program works  Serve as an Ombudsman for the Provider Community coordinating with the CareSource Provider Relations Team.  Answer your questions and assist you with researching an issue at: Phone: (410) Via

Questions and Answers