1. Magellan Healthcare1 Medical Specialty Solutions
Humana Caresource Provider Training/Presented by:
Name: Meghan Murphy
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
RadMD Demo
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
99 Health Plan Clients serving 36M National Lives
23.37M Commercial
2.55M Medicare
10.82M Medicaid
41 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
Musculoskeletal Management (Surgery/IPM)
Physical Medicine (Chiropractic Care, Speech Therapy, Physical and Occupational Therapies)
Provider Profiling & Practice Management Analysis
URAC Accreditation & NCQA Certified

6. Magellan Healthcare’s Prior Authorization Program
Effective August 15, 2019: The Magellan Healthcare Call Center will be available beginning August 5, 2019 for prior authorization for dates of service August 15, 2019 and beyond. Any services rendered on and after August 15, 2019 will require authorization. Only non-emergent procedures performed in an outpatient setting require authorization with Magellan Healthcare.
Procedures Requiring Authorization
CT/CTA
CCTA
MRI/MRA
PET Scan
Excluded from Program: Procedures Performed in the Following Settings:
Hospital Inpatient
Observation
Emergency Room
Surgery Center

7. List of CPT Procedure Codes Requiring Prior Authorization
INSERT HEALTH PLAN SPECIFIC MATRIX SCREEN SHOT
Review Claims/Utilization Review Matrix to determine CPT codes managed by Magellan Healthcare
CPT Codes and their Allowable Billable Groupings
Located on RadMD
Defer to Humana CareSource Policies for Procedures not on Claims/Utilization Review Matrix

8. Responsibility for Authorization
Ordering Provider
Responsible for obtaining prior authorization
Rendering Provider
Ensuring that prior authorization has been obtained prior to providing service
Recommendation to Rendering Providers: Do not schedule test until authorization is received

9. Prior Authorization Process Overview
Or Online Through RadMD
Ordering Physician
Algorithm
Submit Requests by Phone
Information evaluated via algorithm and medical records
Claim
Rendering Provider Performs Service
Service Authorized

10. Clinical Decision Making and Algorithms
Guidelines are reviewed and mutually approved by Humana CareSource and Magellan Healthcare’s Chief Medical Officers
Magellan Healthcare’s algorithms and medical necessity reviews collect key clinical information to ensure that Humana CareSource members are receiving appropriate care prior to more invasive procedures being performed. Our goal – ensure that Humana CareSource members are receiving the appropriate level of care.
Clinical Guidelines available on
Always to be included

11. Patient and Clinical Information Required for Authorization
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)
Refer to the Prior Authorization Checklists on RadMD for more specific information.

12. 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 12

13. 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

14. 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
Be sure to use the Magellan Healthcare Fax Coversheet for all transmissions of clinical information!

15. Prior Authorization Process
Intake level
Initial Clinical Review
Physician Clinical Review
Physicians may:
Approve
Deny
Requests are evaluated using our clinical algorithm
Requests may:
Approve
Require additional clinical review
Pend for clinical validation of medical records
Nurses will review request and may:
Approve
Send to Magellan Healthcare physician for additional clinical review
A peer to peer discussion is always available! 15

16. Notification of Determination
Approval Notification
Member: Letter
Ordering Provider: Fax, and Letter if fax fails
Denial Notification
Member: Letter
Ordering Provider: Fax, Verbal and Letter if fax fails
Authorization Validity Period
60 Days From the Date of Request
Appeal Instructions
In the event of a denial, providers are asked to follow the appeal instructions provided in their denial letter.

17. Magellan Healthcare’s 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

18. Provider Network Claims and Appeals Radiation Safety
Program Components
Provider Network
Claims and Appeals
Radiation Safety

19. Using Humana CareSource Network
Provider Network
Claims and Appeals
Radiation Safety
Using Humana CareSource Network
Advanced Imaging Provider Network:
Humana CareSource will use the Humana CareSource network of Free- Standing Imaging Facilities (FSFs), Hospitals, and In Office Providers as it’s preferred providers for delivering outpatient CT/CTA, MRI/MRA, CCTA, and PET Scan to Humana CareSource members throughout Kentucky.

20. Claims and Appeals How Claims Should be Submitted
Provider Network
Claims and Appeals
Radiation Safety
Claims and Appeals
How Claims Should be Submitted
Claims Appeals Process
Rendering providers/Imaging providers should continue to send their claims directly to Humana CareSource.
Providers are strongly encouraged to use EDI claims submission.
Check on claims status by logging on to the Humana CareSource website at
In the event of a prior authorization or claims payment denial, providers may appeal the decision through Humana CareSource
Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification.
NOTE: Consistent with CMS guidelines, multiple procedure discounts are applied when appropriate.

21. Radiation Safety and Awareness
Provider Network
Claims and Appeals
Radiation Safety
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

22. Magellan Healthcare’s Radiation Awareness Program
Provider Network
Claims and Appeals
Radiation Safety
Magellan Healthcare’s Radiation Awareness Program
Radiation Awareness Program
Identification of High Exposure Members
Point of Service Provider Notification and Opportunities for Provider Education
Promote Member Awareness and Education
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

23. Provider Tools
Toll free authorization and information number – Available Monday – Friday 8AM-8PM EST
Interactive Voice Response (IVR) System for authorization tracking
RadMD Website – Available 24/7 (except during maintenance)
Request authorization (ordering providers only) and view authorization status
Upload additional clinical information
View Clinical Guidelines, Frequently Asked Questions (FAQs), and other educational documents

24. Ordering Provider: Getting Started on RadMD.com
Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations. 1
STEPS:
Click the “New User” button on the right side of the home page.
Select “Physician’s office that orders procedures”
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 user name and password.
NOTE: On subsequent visits to the site, click the “Sign In” button to proceed. 2 3
Offices that will be both ordering and rendering should request ordering provider access, this will allow your office to request authorizations on RadMD and see the status of those authorization requests.

25. Rendering Provider: Getting Started on RadMD.com
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. 1
STEPS:
Click the “New User” button on the right side of the home page.
Select “Facility/office where procedures are performed”
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 user name and password.
NOTE: On subsequent visits to the site, click the “Sign In” button to proceed. 2 3
If you have multiple staff members entering authorizations and you want each person to be able to see all approved authorizations, they will need to register for a rendering username and password. The administrator will have the ability to approve rendering access for each employee. This will allow users to see all approved authorizations under your organization.

26. When to Contact Magellan Healthcare
Providers:
Ordering Providers:
To initiate a request for an authorization please contact Magellan Healthcare via website, or via toll-free number
To check the status of an authorization please contact Magellan Healthcare via website, or Interactive Voice Response (IVR) System
Rendering Providers:
Ordering Providers and Rendering Providers:
For assistance or technical support for RadMD, please contact RadMD Help Desk via or  RadMD ( ).
For any provider education requests or questions specific to Magellan Healthcare and the Medical Specialty Solutions Program, Providers may contact Meghan Murphy, Provider Relations Manager at: or

27. RadMD Demo
Always to be included

28. Confidentiality Statement
The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Humana CareSource 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 Humana CareSource and Magellan Health, Inc.

29. Thanks