Provider Training Program 2010 Presenter: Date:

Provider Training Program Agenda Welcome and Opening Remarks About National Imaging Associates, Inc. Provider Partnership Program Components The Privileging Process Facility Selection Support Program How the Program Works: Authorization Process Algorithms Guidelines Radiation Awareness Authorization Appeals Process Claims Process Claims 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. Provider Privileging: The program includes privileging of the Health Plan’s freestanding facilities and the Health Plan’s in-office providers for advanced and cardiac imaging. The program promotes continuous quality improvement, provides scope of practice limitations and enables consumers to make educated health care decisions. Hospitals are excluded from the privileging program. NIA—A Magellan Health Company 5

The Privileging Process for Rendering Providers

NIA’s Privileging Program NIA has a Comprehensive Program for Evaluating Imaging Providers Selected to Participate in the Health Plan Outpatient Imaging Program Primary Purpose of the NIA Privileging Program: To ensure the Health Plan imaging providers meet the standards required to adequately perform the technical and professional components outlined in the outpatient imaging program. Select information from provider privileging application feeds the Consumer Portal – this data enables members to make educated health care decisions. The Health Plan members have the added assurance that all NIA privileged imaging providers meet the high technical and professional standards required to deliver imaging services safely. Please note: Free-standing facilities and in-office providers should complete a privileging assessment application in order to continue to provide advanced diagnostic imaging services to Health Plan members beginning February 1, NIA—A Magellan Health Company 7

Facility Selection Support Program

Facility Selection Support Goals T he facility selection process is based on patient support and cost effectiveness. Primary consideration is always the clinical aspect of the patient when making facility recommendations. Helps ensure that patients go to quality imaging facilities that are conveniently located. Supports the education of both the provider and patient about cost- effective facility alternatives. Facilitates the delivery of tests at free-standing, outpatient facilities (when appropriate) to support lower costs NIA—A Magellan Health Company 9

How Facilities are Selected During prior authorization, the authorization representative will help the ordering provider select a facility based on: Facilities meeting NIA’s quality requirements and patient’s clinical need Location and cost differential Convenience items important to patient Prior Authorization for a high cost facility will be confirmed with the consumer if there is no clinical justification Facilities located in or close to required zip code. Preference given to lower cost facilities Facilities with requested convenience items Facility Selected All facilities meeting NIA’s approved facility requirements for the indicated test. Facilities also meet the patient’s clinical requirements NIA—A Magellan Health Company 10

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 NIA—A Magellan Health Company 11

The Authorization Process

NIA Prior Authorization is required for: Non-emergent outpatient, short stay and urgent care CT/CTA Scan CCTA MRI/MRA PET Scan Diagnostic Nuclear Medicine Nuclear Cardiology/MPI Echocardiography Stress Echo Any code specifically cited in 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 initial request. NIA—A Magellan Health Company 13

NIA Prior Authorization is not required for: Inpatient, Observation or Emergency Room: CT/CTA CCTA MRI/MRA PET Scan Diagnostic Nuclear Medicine Nuclear Cardiology/MPI Echocardiography Stress Echo NIA—A Magellan Health Company 14

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 15

The NIA Prior Authorization Process NIA—A Magellan Health Company 16 x Physician’s office contacts NIA for prior consultation via web or telephone Procedure is approved by agent Case is transferred to nurse for review Procedure is approved by nurse Case is transferred to physician for review Procedure is approved by a physician reviewer Procedure is denied by a physician reviewer Case is withdrawn by the ordering physician  Nurse level ?  ? Physician level  x Typically 92% of all cases receive final determinations within hours * Requests related to cardiac modalities that require physician review are reviewed by cardiologists Agent level

NIA utilizes OCR technology which allows us to attach the clinical information that you send to be automatically attached to an existing preauthorization request. For the automatic attachment to occur you must use the NIA Fax Cover Sheet as the first page of your fax. You can obtain an NIA Fax Cover Sheet in the following ways. If you have submitted your preauthorization request on-line through RadMD, at the end of your submission of the preauthorization request you are given the option to print the cover sheet. On RadMD click on the link “Request a Fax Cover Sheet”. This will allow you to print the cover sheet for a specific patient. By calling the NIA Clinical Support Department at you can request a cover sheet be faxed to you. If we have sent you a fax requesting additional clinical information the NIA Fax Cover Sheet should accompany the request. Following this process it will facilitate a timely and efficient case review. NIA OCR Fax Cover Sheet – Submission of Clinical Information NIA—A Magellan Health Company 17

Algorithms/Guidelines

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. Some of our current algorithms recommend the substitution of alternate but equally 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 75 board-certified physicians representing radiology and a host of other specialties available for physician to physician discussions. Cardiac services are reviewed by cardiologists. NIA—A Magellan Health Company 19

Enhanced Algorithms  Enhanced algorithms effective January 2010 for Lumbar Spine MRI, Shoulder MRI and Knee MRI  As a result, NIA began asking a few additional questions to obtain more details on the patient and his or her condition. This allowed NIA to make the best clinical decision  NIA's team of clinical experts uses physician-developed criteria and proprietary algorithms based on information from their clinical database  If the authorization is not given during the initial intake process, the case will be forwarded to NIA’s clinical department for review. If the authorization request does not meet clinical criteria at the nurse review level, it will be escalated to physician review. At that point, the NIA physician may ask for more clinical information or request to have a peer discussion with the ordering physician. No request is ever denied without the opportunity to consult with one of NIA’s physicians

Guidelines on RadMD NIA—A Magellan Health Company 21 NIA’s clinical guidelines can be easily accessed on RadMD Open your web browser to Click on the View Clinical Guidelines Link

Guidelines on RadMD cont’d NIA—A Magellan Health Company 22 On the next screen, click on Clinical Guidelines Search

Guidelines on RadMD cont’d NIA—A Magellan Health Company 23 This screen allows you to select: Health Plan Type of Study Exam

Guidelines on RadMD cont’d NIA—A Magellan Health Company 24 The requested clinical guidelines will be displayed in a pop up box in Adobe format. These guidelines can be saved to your computer or printed for reference.

Radiation Awareness

Radiation Awareness Program NIA, in partnership with the Health Plan, has implemented a Radiation Awareness Program to educate the provider community on radiation exposure. Goals of the Program Inform ordering providers of past exposure Offer provider education and consultation Educate providers about the risk vs. benefits of ionizing radiation NIA—A Magellan Health Company 26

Radiation Awareness Program Distinguishing Features Claims-based, member-specific radiation accumulator NIA will advise ordering providers of patients with high level exposure (=>50 mSv cumulatively while with the Health Plan) to radiation during authorization requests and offer peer-to-peer consultation. Provider educational content is available Medical necessity decisions are not impacted by the patient’s radiation exposure - information is intended to assist the provider with the member’s care. More information on radiation awareness is available on our website, NIA—A Magellan Health Company 27

The Authorization Appeals Process

In the event of a denial or you are not satisfied with a medical decision, you may appeal the decision. You will receive a denial letter that contains appeal information. NIA—A Magellan Health Company 29

The Claims Process

How Claims Should be Submitted Rendering providers/imaging providers should continue to send their claims directly to the Health Plan at: PO Box 8200 Danville, PA Providers are strongly encouraged to use EDI claims submission with the Health Plan. NIA—A Magellan Health Company 31

Claims Process Overview Claim Pends claims and routes to NIA Matches Auths and Applies Edits Applies Benefits and Issues Checks and EOP/EOBs NIA GHP Send Member EOB Send Provider Check and EOP NIA—A Magellan Health Company 32

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 34

Self Service Tools and Usage

Multi-Channel Provider Relations Strategy Radiology Provider Interactive Voice Response RadMD.com / MagellanHealth.com High Touch Internet Offerings Initiate Authorization (Ordering Provider) Authorization Inquiry Privileging Provider Relations Staff Provider Forums/Education Centralized and Regional Support IVR – Interactive Voice Response Authorization Inquiry NIA—A Magellan Health Company 36

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 37

NIA Web Site 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 38

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 39

NIA Web Site - Imaging Facilities The NIA web site supports imaging facilities and providers 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 40

Magellan Health Services, Inc. | 41 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 44

Questions and Answers