Magellan Healthcare 1 Medical Specialty Solutions Provider Training

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

Magellan Healthcare Training Program 2

Magellan Healthcare Program Agenda Introduction to Magellan Healthcare Our Program 1. 2. 3. Authorization Process Other Program Components Provider Tools and Contact Information Review of Website - www. Rad. MD. com Questions and Answers 3

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

Magellan Healthcare Highlights Product Portfolio 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. 43 M National Lives • 16. 14 M Commercial; • 1. 39 M Medicare; • 9. 90 M 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) • 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 5

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 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 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 • Procedures Requiring Prior Authorization Excluded from Program: Procedures Performed in the Following Settings: 6 • Hospital Inpatient (excluding MSK Surgery) • Observation • Emergency Room/Urgent Care Facility

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 Rad. MD • Defer to Magellan Complete Care of Virginia Policies for Procedures not on Claims/Utilization Review Matrix 7

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 Recommendation to Rendering Providers: Do not schedule test until authorization is received 8

Prior Authorization Process Overview Algorithm Ordering Physician Claim 9 Telephone Magellan Healthcare’s Call Center Rendering Provider Performs Service Online Through Rad. MD www. Rad. MD. com Service Authorized

NIA’s Clinical Foundation & Review Clinical Guidelines Are the Foundation 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 Clinical Algorithms collect pertinent information Algorithms are a branching structure that change depending upon the answer to each question Fax/Upload Clinical Information (upon request) 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 Clinical Review by NIA’s Specialty oncology and MSK. NIA reviews key clinical information to ensure Magellan Complete Care members are receiving MSK & Radiation Oncology Clinicians appropriate care based on their clinical condition Peer-to-Peer Discussion 10 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

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 1 1

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) Refer to the Prior Authorization Checklists on Rad. MD for more specific information. 12

Tip Sheets Most Requested Advanced Imaging Procedures 13

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 94660 95810 14 Sleep disorder treatment initiation and management Sleep study, attended Allowable Billed Groupings 94660 95805, 95808, 95809, 95810, 95811

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 15

Submitting Additional Clinical Information/Medical Records to Magellan Healthcare • Two ways to submit clinical information to Magellan Healthcare ‒ Via Fax ‒ Via Rad. MD Upload • Use the Fax Coversheet (when faxing clinical information to Magellan Healthcare) • Additional copies of Fax Coversheets can also be printed from Rad. MD or requested via the Call Center @ 1 -800 - 424 -4524 Be sure to use the Magellan Healthcare Fax Coversheet for all transmissions of clinical information! 16

Notification of Determination • Approval Notification • Authorization Validity Period • Denial Notification • Appeal Instructions • In the event of a denial, • RBM, IPM, MSK Surgery, Cardiac providers are asked to follow and Sleep - 90 days from the appeal instructions date of the request provided in their denial letter Radiation Oncology = 180 days from the date of the request 17

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 1 -800 -424 -4524 18

Other Program Components

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 20

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

Radiation Safety and Awareness • Studies suggest a significant increase in cancer in dose estimates in excess of 50 m. Sv • 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 Safety Tools Radiation Awareness Education • Promote Provider and Member Awareness and Education Radiation Calculator www. radiationcalculator. com 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 that Make it Easy for Providers to Partner with Magellan Healthcare • Toll free authorization and information number 1 -800 -424 -4524 • Available Monday – Friday 8 am – 8 pm EST • Interactive Voice Response (IVR) System • Rad. MD 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 24

Ordering Provider: Getting Started on Rad. MD. com Everyone in your organization is required to have their own separate user name and password due to HIPAA regulations. STEPS: 1. Click the “New User” button on the right side of the home page. 2. Select “Physician’s office that orders radiology exams” 3. Fill out the application and click the “Submit” button. • You must include your e-mail 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. 25 1 2 3

Rendering Provider: Getting Started on Rad. MD. com IMPORTANT 1 • 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: 1. Click the “New User” button on the right side of the home page 2. Select “Imaging Facility or Hospital that performs radiology exams” 3. Fill out the application and click the “Submit” button. • You must include your e-mail 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. 26 2 3

Dedicated Provider Relations Contact Information Magellan Healthcare Dedicated Provider Relations Manager: Name: Charmaine S. Everett Phone: 1 -800 -450 -7281 ext. 32615 or at (410) 953 -2615 Email: cseverett@magellanhealth. com Providing educational tools to Medical Specialty Ordering Providers and Facilities on processes and procedures. Magellan Complete Care of Virginia provider Service Department Phone: 1 -800 -424 -4524 27

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. 28

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