Provider Training Program 2010 Presenter Date

Provider Training Program Agenda Welcome and Opening Remarks About National Imaging Associates, Inc. How the Program Works: Authorization Process Authorization Appeals Process Provider Self-Service Tools (RadMD and IVR) RadMD Demonstration NIA Provider Relations and Contact Information Questions and Answers NIA—A Magellan Health Company 2

About National Imaging Associates National Imaging Associates (NIA) - chosen by national and regional health plans, serving more than 19 million members, and offering: Distinctive clinical focus National Committee for Quality Assurance accreditation and Utilization Review Accreditation Commission certification Stability reinforced by parent company, Magellan Health Services Enhanced operational competencies Strong IT capabilities Comprehensive patient support tools Financial stability promoting growth and investment in innovative technology Focus and Results - Maximizing quality diagnostic services and promoting patient safety through: A clinically-driven process that safeguards appropriate diagnostic treatment for Geisinger Health Plan 1 members. Convenient access to a network of qualified providers 1 Geisinger Health Plan, Geisinger Indemnity Insurance Company, and Geisinger Quality Options, Inc. shall be collectively referred to herein as "the Health Plan NIA is accredited by NCQA and URAC NIA—A Magellan Health Company 3

The NIA Provider Partnership Model Dedication to Provider Service and Convenience Dedicated provider relations staff Authorization call center Interactive Voice Response (IVR) tool Innovative provider support tool – RadMD Education and training programs Ongoing outreach to providers Provider newsletters NIA—A Magellan Health Company 4

Program Components Utilization Management/Authorizations: NIA's proprietary, evidence-based decision algorithms support scripting for call center representatives or online, leading to quick procedure approval or consultation with our radiology experts. Information and Transaction Tools: Our online resource, gives ordering providers the ability to request and obtain authorizations, reference lists of nearby imaging facilities, locate authorizations and submit 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. NIA—A Magellan Health Company 5

The Authorization Process

NIA Prior Authorization is required for: Non-emergent outpatient CT/CTA Scan MRA/MRI PET Scan Nuclear Cardiology Any code specifically cited in the The Health Plan/NIA Billable CPT ® Code Claims Resolution Matrix. ALL other procedures will be adjudicated and paid by The Health Plan per their guidelines. Authorizations are valid for sixty (60) days from date of determination. NIA—A Magellan Health Company 7

NIA Prior Authorization is not required for: Inpatient, Observation or Emergency Room: CT/CTA Scan MRI/MRA PET Scan Nuclear Cardiology NIA—A Magellan Health Company 8

Clinical Validity of Algorithms NIA currently reviews more than 450,000 advanced imaging requests each month. All algorithms and guidelines are reviewed and approved by The Health Plan 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 clinically appropriate test early in an episode of care. Consultative communication is a hallmark of NIA – NIA has a team of 65 board-certified physicians representing radiology and a host of other specialties available for physician to physician discussions. NIA—A Magellan Health Company 9

NIA’s Authorization Process 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 and may not be billed to The Health Plan members. If the radiologist or rendering provider feels that, in addition to the study already authorized, an additional study is needed the radiologist or rendering provider should proceed with the additional study and contact NIA within 1 business day to initiate the medical necessity review process. 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 prior authorization numbers are not needed for CT-guided biopsy and CT-guided radiation therapy. NIA—A Magellan Health Company 10

The NIA Prior Authorization Process NIA—A Magellan Health Company 11 x Physician’s office contacts NIA for prior consultation via web or telephone 100% cases Procedure is approved by agent ~70% cases Case is transferred to nurse for review ~30% cases Procedure is approved by nurse ~10% 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 Case is withdrawn by the ordering physician  Nurse level ?  ? Physician level  x Call time of approximately 5 minutes Typically 92% of all cases receive final determinations within hours * Requests related to Coronary Artery Disease that require physician review are reviewed by cardiologists Agent level

The Authorization Appeals Process

In the event of a denial or you are not satisfied with a medical decision, you may appeal the decision through The Health Plan. You will receive a denial letter that contains appeal information. NIA—A Magellan Health Company 13

The Claims Process

How Claims Should be Submitted Rendering providers/imaging providers should continue to send their claims directly to The Health Plan. Providers are strongly encouraged to use EDI claims submission with The Health Plan. NIA—A Magellan Health Company 15

The Claims Appeals Process

In the event of a prior authorization or claims payment denial, you may appeal the decision through The Health Plan. Follow the instructions on your denial letter or explanation of payment notification. NIA—A Magellan Health Company 17

Self Service Tools and Usage

Multi-Channel Provider Relations Strategy NIA—A Magellan Health Company 19 Radiology Provider Interactive Voice Response RadMD.com High Touch Internet Offerings Initiate authorization (ordering provider) Authorization Inquiry Provider Relations Staff Provider support and inquiries Provider education Centralized and regional support IVR – Interactive Voice Response Authorization Inquiry

Self Service Tools and Uses Interactive Voice Response (IVR) Use tracking number to check case status Web site: Use tracking number to review an exam request NIA—A Magellan Health Company 20

NIA Website The NIA web site gives providers access to: Information concerning approved authorizations. Go to and login with username and password. Search the site using the patient’s ID number, name or authorization number. NIA—A Magellan Health Company 21

NIA Web Site – Ordering Providers The NIA web site supports ordering providers with: Instant, easy access to high tech imaging prior authorization information Online authorization of most cases; pended cases will be resolved through our Clinical Review Department Up to the hour information on member authorizations, including date initiated, date approved, exam category, valid billing codes and much more We encourage ordering providers to submit all requests on line. NIA—A Magellan Health Company 22

NIA Web Site - Imaging Facilities The NIA web site supports imaging facilities with: User friendly, near-real-time Internet tool Available Monday – Friday, 5:00 a.m. to 12:00 a.m. Eastern Time; Saturday 8:00 a.m. to 1:00 p.m. Eastern Time Log on to RadMD for direct access to members’ authorization information, including: Date initiated Exam requested Valid billing codes (CPT) Current provider news Access to a full range of helpful content, Diagnostic Imaging Guidelines and Quick Reference Guide NIA—A Magellan Health Company 23

Magellan Health Services, Inc. | 24 Login and 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 username and password. HIPAA regulations require everyone in your organization to have his or her own username and password. On subsequent visits to the site, click the login button to proceed. To get started, visit

RadMD Demonstration

NIA Provider Relations

Provider Relations Structure and Portals Kristy S. Over, dedicated NIA Provider Relations Manager for The Health Plan providers will: Serve as a liaison for The Health Plan Provider Relations and NIA. Contact information: Phone at NIA—A Magellan Health Company 27

Questions and Answers