1. Provider Training Program
May 2017

2. The Sparrow Pyramid

3. Care to Care Overview
Founded in 2007 by Radiologists and Seasoned Health Care Executives dissatisfied with the Radiology Benefits Management processes
Care to Care was designed from the ground up to avoid processes that delayed care
Our software was designed in-house with the sole purpose of fostering prior authorization and decision support
Criteria are broadly researched, free of jargon and frivolous requirements
All physician reviewers are board certified and specialists in the field that they oversee
Capable of credibly discussing issues with ordering physicians
Always available to discuss cases that do not meet criteria

4. Training Goals
Fully understand the Radiology Benefit Management Program for Physicians Health Plan
Provide you with information to help navigate through the prior authorization process for advanced imaging modalities
Familiarize you with the on-line authorization system
Offer sufficient means of research & educational material for future use
Presentation will be available online:

5. Radiology Benefits Management Program Overview
Purpose:
Designed to enhance the quality of services delivered to patients and reduce unnecessary radiation associated with advanced imaging
Best Practice:
Focus on necessity of requested procedures, where emphasis is put on patients’ health and treatment options
Uses evidence-based clinical criteria to promote the right test at the right time
Safety:
Utilization and quality components employed in the program focus to minimize patient risk of receiving unnecessary radiation
Program designed to be collaborative by offering physicians the opportunity to consult with a radiologist or cardiologist reviewer at any point during the prior authorization process

6. Radiology Benefits Management Program Overview
Prior-authorization is required for the following services when performed in free standing diagnostic imaging facilities, provider offices or outpatient hospital settings:
MRI/MRA
CT/CTA
PET
PET/CT
Nuclear Cardiology studies
Complete list of CPT codes requiring prior authorization will be available online at in the “Covered Services Lists” section.

7. Prior-Authorization Requirements
Authorization is NOT required if services are provided as part of:
Hospital inpatient stay
Emergency Room visit
Intra-operative procedures

8. Prior-Authorization Requirements
Advanced imaging and nuclear cardiology procedures with dates of service June 1, 2017 and forward will require prior-authorization from Care to Care

9. Prior-Authorization Contacts
Ordering providers can submit a request via:
Web:
Phone: (888)
Available Monday through Friday, 8 a.m. to 6 p.m. EST
Fax: (646)
Web and Fax Available 24/7

10. Care to Care Clinical Management
Intake
Case Review
Completed
Goal
Approved
Peer-to-Peer
Reviews
100% Provider Satisfaction
Web
Phone Fax
Modified/ Withdrawn/ Denied
Approved at
Intake Review
80%

11. Prior-Authorization Process
Authorization via CarePortal (online web tool)
Authorization via Phone (contact center)
Authorization via Fax (prior authorization form)
Clinically Urgent Requests
We strongly encourage providers to submit expedited and urgent requests via phone to ensure a prompt response
All clinically urgent requests are processed within 1 business day
Medically emergent requests performed outside regular business hours must be sent to Care to Care within 48 hours for retrospective review

12. Required Information for PA Request
IMPORTANT: Provider/office staff must have the following information available at time of request:
Member Data
Member ID
Patient name
Date of birth
Provider Data
Referring physician name, address, and contact information
Ordering physician specialty & NPI
Rendering facility name, address, and contact information

13. Required Information for PA Request
Clinical Data – A brief summary of clinical indications for services requested with ICD-10 code(s)
Major complaints or symptoms
Rule out diagnosis
Results of prior tests or imaging procedures
Outcome of prior treatment, including type and duration, for the same medical indication
Submission of office notes relevant to the study requested is recommended
Other relevant clinical information

14. Prior Authorization Fax Form

15. Determination Process
Requests submitted via the CarePortal can be approved immediately when sufficient information is provided and clinical criteria is met
Requests submitted via phone are usually approved within minutes when sufficient information is provided and clinical criteria is met
Authorization number is issued upon determination
Authorizations are valid for 60 days
Determinations can take up to 7 business-days if clinical criteria is not met or information is missing
Care to Care will contact the ordering provider’s office requesting missing clinical information

16. Authorization Status
Approved – requested service has been authorized for 60- day timespan
Pending – further level of review or additional documentation is still required. Care to Care will make multiple attempts to contact the ordering provider’s office for any outstanding information
Withdrawn – requested service is deemed to be unnecessary by the ordering provider, typically through peer to peer consultation process
Denied – requested service has been denied for lack of medical necessity or lack of information and rationale provided for further explanation. Appeal process information is included with adverse determination letters
Void – requested service ordered in error, very rare

17. Authorization Status Notifications
Determination Notices:
Will be mailed to the member and faxed to the ordering/referring provider’s office
Can be faxed to the rendering facility upon request
Rendering facility and ordering provider’s office can monitor authorization status via CarePortal

18. Peer to Peer Consultation Process
Medical Director Consultation:
Ordering/Referring Provider may call Care to Care Medical Director line to speak with a Board Certified Radiologist or Board Certified Cardiologist at any point when they are ordering a study
Modifications to an Authorization:
If an authorized study is changed to another procedure requiring prior authorization, please call Care to Care prior to rendering the service
Example:
Contrast enhanced study Non-contrast study
CT – Chest MRI – Chest
MRI – Upper extremity other than joint MRI – Any joint of upper extremity
Once a modification is approved, an updated authorization notification will be faxed to the ordering provider

19. Appeal Process
All appeals will be processed by Physicians Health Plan and follow all Physicians Health Plan’s guidelines
Appeal procedures are included within all Denial Letters
Appeals must be sent to Physicians Health Plan within 90 calendar days from receipt of the denial notice
A provider appeal must be submitted in writing and include any pertinent documentation to support the appeal
A letter or a Provider Appeal Form located on must be submitted
Mail or fax the appeal to:
Physicians Health Plan
Attn: Customer Service, Provider Appeals,
P.O. Box 30377, Lansing, MI 48909
(P): or
(F):
Removed “Providers must appeal a denial VERBALLY”

20. Appeal Process
Questions related to medical necessity appeals will be handled by Physicians Health Plan's Utilization Management Department at:
Phone (517) or (866)
Fax (517)
Questions related to denial rationales will be handled by Care to Care at (888)
Any questions related to a claim denial will be handled by Physicians Health Plan’s Customer Service Department at (517) or (800)
Removed “Providers must appeal a denial VERBALLY”

21. CarePortal Resources
Care to Care’s CarePortal, offers useful tools, information, and resources to better assist you in the prior authorization process
View Clinical Criteria
View a Quick Reference Guide to Imaging
Download a Prior Authorization Request Fax Form
Request a Prior Authorization
Perform a Status Check on an Authorization Request
Only ordering physician’s office may submit an authorization request

22. CarePortal Registration Process
Access CarePortal through the following link:
Establishing Primary User Web Portal Account:
Each user must have a unique address
Every registration request will be reviewed/authenticated, and must connect through a valid business address
If a practice or group has more than one ordering provider, additional physicians can be associated to the primary user’s account
Non-Clinicians can submit requests for providers if they are registered as a sub-user to an existing account

23. CarePortal Registration Process
CarePortal Registration completed by primary user

24. CarePortal Registration Process
Select a participating provider at your practice to validate your registration

25. CarePortal Registration Process
Review your registration information and submit your registration request
User will receive a confirmation to verify registration

26. CarePortal Registration Process
Adding new Ordering Providers to Account
Same Option Available for Rendering Facilities
Changed to “Ordering Providers” not “referring physicians”

27. CarePortal Registration Process
Adding additional Users to your Account
Managed by Primary Account
Allows multiple users to reference same Order History
Similar to initial registration page

28. Submitting Prior Authorization Online
Step 1: Log onto the portal
HIPAA Disclosure Agreement
must be accepted to login
Step 2: Home page is displayed. Click on ‘Authorization Request’

29. Submitting Prior Authorization Online
Step 3: Search for the Member through Patient Lookup. Member ID# and at least one other identification item is required for this lookup.

30. Submitting Prior Authorization Online
Step 4: Select and confirm the Ordering/Referring Physician

31. Submitting Prior Authorization Online
Step 4: Once referring physicians have been added to your account, you may select a physician from the drop down menu.

32. Submitting Prior Authorization Online
Step 5: Select and confirm the Rendering Facility

33. Submitting Prior Authorization Online
Step 6: Fill in the required fields including requested Procedure Code(s) and Primary Diagnosis Code(s)

34. Submitting Prior Authorization Online
Step 7: Select the patient’s signs and symptoms from the Clinical Criteria Tree that correspond with your requested procedure
Required for Automatic Approvals

35. Submitting Prior Authorization Online
Step 8: If clinical criteria is not met through the Clinical Criteria Tree, complete the clinical history fields and/or attach member records relevant to the request

36. Submitting Prior Authorization Online
Step 9: Review submission screen with authorization number and status of the request (Pending or Approved)
Reference Number

37. Reviewing a Pending or Completed Request
You will be notified by once the submission of your request is complete:
Automatic Approvals will receive an approval letter via fax, which you can also download from the CarePortal
Reference Number
Changed “Authorization Letter” to “Approval Letter”

38. Reviewing a Pending or Completed Request
Select the ‘Authorization Inquiry’ tab on your homepage:
Then enter your patient’s demographic information:
Or select the ‘Order History’ link on your homepage:

39. Reviewing a Pending or Completed Request
Enter a date range, Member ID, or your case Reference Number:

40. Member Eligibility Lookup
Enter member demographics and select “Search”
If member is not found, please call (888)

41. CarePortal Tutorial
A video tutorial of the CarePortal and the Authorization process is available at

42. Recap CarePortal Resources
Care to Care’s CarePortal, offers useful tools, information, and resources to better assist you in the prior authorization process
View Clinical Criteria
View a Quick Reference Guide to Imaging
Download a Prior Authorization Request Fax Form
Request a Prior Authorization
Perform a Status Check on an Authorization Request
Only ordering physician’s office may submit an authorization request

43. Thank you! Question and Answers