1. Magellan Healthcare1 Medical Specialty Solutions Provider Training Program
1 –National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc.

2. Magellan Healthcare Training Program

3. Magellan Healthcare Program Agenda
Introduction to Magellan Healthcare
Our Program
Authorization Process
Other Program Components
Provider Tools and Contact Information
Review of Website -
Questions and Answers

4. >20% clinical disapproval rates
A Unique Vision of Care
As the nation’s leading specialty health care management company, we deliver comprehensive and innovative solutions to improve quality outcomes and optimize cost of care
>20% clinical disapproval rates 4

5. Magellan Healthcare Highlights
Magellan Healthcare Facts
Providing Client Solutions since 1995
Magellan Acquisition (2006)
Headquartered in Scottsdale, AZ
Business supported by two National Call Operational Centers
Industry Presence
79 Health Plan Clients serving 27.43M National Lives
16.14M Commercial;
1.39M Medicare;
9.90M Medicaid
37 states
Clinical Leadership
Strong panel of internal Clinical leaders – client consultation; clinical framework
Supplemented by broad panel of external clinical experts as consultants (for guidelines)
Product Portfolio
Advanced Diagnostic Imaging
Cardiac Solutions
Radiation Oncology
Ob Ultrasound
Genetic Testing
Musculoskeletal Management (Surgery/IPM)
Chiropractic Care, Speech Therapy, Physical and Occupational Therapies
Sleep Management
Emergency Department Clinical Decision Support
Provider Profiling & Practice Management Analysis
URAC Accreditation & NCQA Certified

6. Magellan Healthcare’s Prior Authorization Program
August 1, 2017
Only non-emergent procedures performed in an outpatient setting (with the exception of Inpatient Musculoskeletal (MSK) Surgeries) require prior authorization with Magellan Healthcare
Procedures Requiring Prior Authorization
Diagnostic Imaging –
MR, CT/CTA, PET, CCTA, Nuclear Cardiology/MPI, Stress Echo, Echocardiography
Cardiac Interventions
Catheterizations and Implantable Devices
Musculoskeletal (MSK) Procedures
Interventional Pain Management-
Spinal Epidural Injections
Facet Joint Injections
Facet Joint Denervation/Neurolysis
MSK Surgery– (Inpatient and Outpatient)
Lumbar Microdiscectomy
Lumbar Decompression
Lumbar Spine Fusion (Arthrodesis)
Cervical Anterior Decompression with Fusion –Single & Multiple Levels
Cervical Posterior Decompression with Fusion –Single & Multiple Levels
Cervical Posterior Decompression (without fusion)
Cervical Artificial Disc Replacement
Cervical Anterior Decompression (without fusion)
Radiation Oncology Management
All Radiation Therapy for All Cancer
All Other Conditions using Intensity Modulated Radiation Therapy
Stereotactic Radiation Therapy and Proton Beam
Sleep Studies
Always to be included
Insert Effective Date
Confirm modalities
Confirm Business Rules for Urgent Care & Surgery Center
Excluded from Program:
Procedures Performed in
the Following Settings:
Hospital Inpatient (excluding MSK Surgery)
Observation
Emergency Room/Urgent Care Facility

7. List of CPT Procedure Codes Requiring Prior Authorization
Review Claims/Utilization Review Matrix to determine CPT codes managed by Magellan Healthcare
Separate Claim Matrices for:
Diagnostic Imaging Procedures
Musculoskeletal (MSK) Care Management
Radiation Oncology
CPT Codes and their Allowable Billable Groupings
Located on RadMD
Defer to Magellan Complete Care of Virginia Policies for Procedures not on Claims/Utilization Review Matrix
Always to be included
Customize screen shot of matrix to fit your HP

8. Responsibility for Authorization
Ordering Provider Responsible for obtaining prior authorization
Rendering Provider, Radiation Oncologist, Cancer Treatment Facility or Facility/Place of Service Ensuring that prior authorization has been obtained prior to providing service
Always to be included
Recommendation to Rendering Providers: Do not schedule test until authorization is received

9. Prior Authorization Process Overview
Ordering Physician
Telephone Magellan Healthcare’s Call Center
Online Through RadMD
Algorithm
Claim
Rendering Provider Performs Service
Service Authorized
Always to be included

10. NIA’s Clinical Foundation & Review
Clinical guidelines were developed by practicing specialty physicians, literature reviews, and evidence base. Guidelines are reviewed and mutually approved by Magellan Complete Care and Magellan Healthcare Chief Medical Officers and clinical experts
Algorithms are a branching structure that change depending upon the answer to each question
When requested, the patient’s medical record will be required for validation of clinical criteria before an approval can be made
NIA has a specialized clinical team focused on radiation oncology and MSK. NIA reviews key clinical information to ensure Magellan Complete Care members are receiving appropriate care based on their clinical condition
Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines. Our goal – ensure that Magellan Complete Care members are receiving appropriate care
Clinical Guidelines Are the Foundation
Clinical Algorithms collect pertinent information
Fax/Upload Clinical Information (upon request)
Clinical Review by NIA’s Specialty MSK & Radiation Oncology Clinicians
Peer-to-Peer Discussion

11. Document Review
Magellan Healthcare 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
Always to be included 11

12. Required Information for Authorization: Patient and Clinical Information
GENERAL
Includes things like ordering physician information, Member information, rendering provider information, requested examination, etc.
CLINICAL INFORMATION
Includes clinical information that will justify examination, symptoms and their duration, physical exam findings
Preliminary procedures already completed (e.g., x-rays, CTs, lab work, ultrasound reports, scoped procedures, referrals to specialist, specialist evaluation)
Reason the study is being requested (e.g., further evaluation, rule out a disorder)
Always to be included
Refer to the Prior Authorization Checklists on RadMD for more specific information.

13. Tip Sheets Most Requested Advanced Imaging Procedures
Always to be included
Customize screen shot of matrix to fit your HP

14. Sleep Management for Magellan Complete Care of Virginia
Magellan Healthcare’s sleep solution for MCC VA manages attended sleep assessments and treatment initiation/management services using prior authorization and clinical reviews
The MCC-VA program does NOT manage home sleep tests (because this is not a covered benefit) or sleep treatment devices (e.g. CPAP machines)
Authorized CPT Code
Description
Allowable Billed Groupings
94660
Sleep disorder treatment initiation and management
95810
Sleep study, attended
95805, 95808, 95809, 95810, 95811
Always to be included

15. Magellan Healthcare to Ordering Provider: Request for Additional Clinical Information
A fax is sent to the provider detailing what clinical information that is needed, 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
Always to be included

16. Submitting Additional Clinical Information/Medical Records to Magellan Healthcare
Two ways to submit clinical information to Magellan Healthcare
Via Fax
Via RadMD Upload
Use the Fax Coversheet (when faxing clinical information to Magellan Healthcare)
Additional copies of Fax Coversheets can also be printed from RadMD or requested via the Call
Always to be included
Be sure to use the Magellan Healthcare Fax Coversheet for all transmissions of clinical information!

17. Notification of Determination
Approval Notification
Denial Notification
Authorization Validity Period
RBM, IPM, MSK Surgery, Cardiac and Sleep days from the date of the request
Radiation Oncology = 180 days from the date of the request
Appeal Instructions
In the event of a denial, providers are asked to follow the appeal instructions provided in their denial letter

18. Magellan Healthcare’s Re-review and Urgent/Expedited Authorization Process
Re-review Process
Re-Reviews will be allowed within 5 business days of initial denial determination
Urgent Authorization Process
If an urgent clinical situation exists outside of a hospital emergency room, please contact Magellan Healthcare immediately with the appropriate clinical information for an expedited review

19. Other Program Components

20. Using Magellan Complete Care of Virginia’s Network
Provider Network:
Magellan Complete Care of Virginia will use their network of Providers/Facilities for delivering Medical Specialty Solutions services to Magellan Complete Care of Virginia’s membership

21. Claims How Claims Should be Submitted Claims Appeals Process
Rendering providers/Imaging providers should send their claims directly to Magellan Complete Care of Virginia.
Providers are strongly encouraged to use EDI claims submission.
Check on claims status by logging on to the Magellan Complete Care website at:
In the event of a prior authorization or claims payment denial, providers may appeal the decision through Magellan Complete Care of Virginia
Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification.

22. Radiation Safety and Awareness
Studies suggest a significant increase in cancer in dose estimates in excess of 50 mSv
U.S. population exposed to nearly six times more radiation from medical devices than in 1980
CT scans and nuclear studies are the largest contributors to increased medical radiation exposure
Magellan Healthcare has developed Radiation Awareness Tools and Safety Programs designed to create patient and physician awareness of radiation concerns

23. Magellan Healthcare’s Radiation Safety Tools
Radiation Calculator
Over 8,000 visits to the website from 89 countries
Apple, Android and Facebook App available
Average rating: 4 out of 5 stars
Radiation Awareness Education
Promote Provider and Member Awareness and Education

24. Provider Tools
Provider Tools that Make it Easy for Providers to Partner with Magellan Healthcare
Toll free authorization and information number
Available Monday – Friday 8am – 8pm EST
Interactive Voice Response (IVR) System
RadMD Website – Available 24/7 (except during maintenance)
Different functionality for ordering and facility/place of service providers
Request authorization and view authorization status
Upload additional clinical information
View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents

25. Ordering Provider: Getting Started on RadMD.com1
Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations.
STEPS:
Click the “New User” button on the right side of the home page.
Select “Physician’s office that orders radiology exams”
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 Magellan Healthcare-approved username and password.
NOTE: On subsequent visits to the site, click the “Sign In” button to proceed. 2 3

26. Rendering Provider: Getting Started on RadMD.com1
IMPORTANT
Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations.
Designate an “Administrator” for the facility who manages the access for the entire facility.
STEPS:
Click the “New User” button on the right side of the home page
Select “Imaging Facility or Hospital that performs radiology exams”
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 Magellan Healthcare-approved username and password.
NOTE: On subsequent visits to the site, click the “Sign In” button to proceed. 2 3

27. Dedicated Provider Relations Contact Information
Magellan Healthcare Dedicated Provider Relations Manager:
Name: Charmaine S. Everett
Phone: ext or at (410)
Providing educational tools to Medical Specialty Ordering Providers and Facilities on processes and procedures.
Magellan Complete Care of Virginia provider Service Department
Phone:

28. Confidentiality Statement for Providers
The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Magellan Complete Care of Virginia members. 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 Complete Care of Virginia and Magellan Health, Inc.

29. Thanks