May 2017 The Sparrow Pyramid 1 Care to Care Overview Founded in 2007 by Radiologists and Seasoned Health Care Executives dissatisfied with the Radiology Benefits Management processes Care to Care ID: 760627
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Provider Training Program
May 2017
Slide2The Sparrow Pyramid
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Slide3Care to Care Overview
Founded in 2007 by Radiologists and Seasoned Health Care Executives dissatisfied with the Radiology Benefits Management processesCare 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 supportCriteria are broadly researched, free of jargon and frivolous requirements All physician reviewers are board certified and specialists in the field that they overseeCapable of credibly discussing issues with ordering physiciansAlways available to discuss cases that do not meet criteria
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Slide4Training 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 modalitiesFamiliarize you with the on-line authorization system Offer sufficient means of research & educational material for future usePresentation will be available online:www.caretocare.comwww.phpmichigan.com
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Slide5Radiology Benefits Management Program Overview
Purpose:Designed to enhance the quality of services delivered to patients and reduce unnecessary radiation associated with advanced imagingBest Practice: Focus on necessity of requested procedures, where emphasis is put on patients’ health and treatment optionsUses evidence-based clinical criteria to promote the right test at the right timeSafety: Utilization and quality components employed in the program focus to minimize patient risk of receiving unnecessary radiationProgram 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
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Slide6Radiology 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/MRACT/CTAPETPET/CTNuclear Cardiology studiesComplete list of CPT codes requiring prior authorization will be available online at https://caretocare.careportal.com in the “Covered Services Lists” section.
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Slide7Prior-Authorization Requirements
Authorization is NOT required if services are provided as part of:Hospital inpatient stayEmergency Room visitIntra-operative procedures
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Slide8Prior-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
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Slide9Prior-Authorization Contacts
Ordering providers can submit a request via: Web: https://php.careportal.com Phone: (888) 223-4144Available Monday through Friday, 8 a.m. to 6 p.m. EST Fax: (646) 502-5044Web and Fax Available 24/7
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Slide10Care to Care Clinical Management
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Intake
Case Review
Completed
Goal
Web
Web
Phone
Fax
Approved at
Intake Review
80%
Peer-to-Peer
Reviews
Approved
Modified/
Withdrawn/
Denied
100%
Provider
Satisfaction
Slide11Prior-Authorization Process
Authorization via CarePortal (online web tool)Authorization via Phone (contact center)Authorization via Fax (prior authorization form)Clinically Urgent RequestsWe strongly encourage providers to submit expedited and urgent requests via phone to ensure a prompt responseAll clinically urgent requests are processed within 1 business dayMedically emergent requests performed outside regular business hours must be sent to Care to Care within 48 hours for retrospective review
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Slide12Required Information for PA Request
IMPORTANT: Provider/office staff must have the following information available at time of request:Member DataMember IDPatient name Date of birthProvider DataReferring physician name, address, and contact informationOrdering physician specialty & NPIRendering facility name, address, and contact information
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Slide13Required Information for PA Request
Clinical Data – A brief summary of clinical indications for services requested with ICD-10 code(s)Major complaints or symptomsRule out diagnosisResults of prior tests or imaging proceduresOutcome of prior treatment, including type and duration, for the same medical indicationSubmission of office notes relevant to the study requested is recommendedOther relevant clinical information
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Slide14Prior Authorization Fax Form
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Slide15Determination Process
Requests submitted via the CarePortal can be approved immediately when sufficient information is provided and clinical criteria is metRequests submitted via phone are usually approved within minutes when sufficient information is provided and clinical criteria is metAuthorization number is issued upon determination Authorizations are valid for 60 daysDeterminations can take up to 7 business-days if clinical criteria is not met or information is missingCare to Care will contact the ordering provider’s office requesting missing clinical information
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Slide16Authorization Status
Approved – requested service has been authorized for 60-day timespanPending – 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 informationWithdrawn – requested service is deemed to be unnecessary by the ordering provider, typically through peer to peer consultation processDenied – 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 lettersVoid – requested service ordered in error, very rare
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Slide17Authorization Status Notifications
Determination Notices:Will be mailed to the member and faxed to the ordering/referring provider’s officeCan be faxed to the rendering facility upon requestRendering facility and ordering provider’s office can monitor authorization status via CarePortal
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Slide18Peer 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 studyModifications to an Authorization:If an authorized study is changed to another procedure requiring prior authorization, please call Care to Care prior to rendering the serviceExample: Contrast enhanced study Non-contrast studyCT – Chest MRI – ChestMRI – Upper extremity other than joint MRI – Any joint of upper extremityOnce a modification is approved, an updated authorization notification will be faxed to the ordering provider
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Slide19Appeal Process
All appeals will be processed by Physicians Health Plan and follow all Physicians Health Plan’s guidelinesAppeal procedures are included within all Denial LettersAppeals 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 appealA letter or a Provider Appeal Form located on www.phpmichigan.com must be submittedMail or fax the appeal to:Physicians Health Plan Attn: Customer Service, Provider Appeals, P.O. Box 30377, Lansing, MI 48909(P): 517.364.8500 or 800.832.9186(F): 517.364.8411
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Slide20Appeal Process
Questions related to medical necessity appeals will be handled by Physicians Health Plan's Utilization Management Department at:Phone (517)364-8560 or (866)203-0618Fax (517)364-8409 Questions related to denial rationales will be handled by Care to Care at (888)223-4144Any questions related to a claim denial will be handled by Physicians Health Plan’s Customer Service Department at (517)364-8500 or (800)832-9186
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Slide21CarePortal Resources
Care to Care’s CarePortal, https://php.careportal.com, offers useful tools, information, and resources to better assist you in the prior authorization processView Clinical CriteriaView a Quick Reference Guide to ImagingDownload a Prior Authorization Request Fax FormRequest a Prior AuthorizationPerform a Status Check on an Authorization Request Only ordering physician’s office may submit an authorization request
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Slide22CarePortal Registration Process
Access CarePortal through the following link: https://php.careportal.com Establishing Primary User Web Portal Account:Each user must have a unique e-mail addressEvery registration request will be reviewed/authenticated, and must connect through a valid business e-mail addressIf a practice or group has more than one ordering provider, additional physicians can be associated to the primary user’s accountNon-Clinicians can submit requests for providers if they are registered as a sub-user to an existing account
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Slide23CarePortal Registration Process
CarePortal Registration completed by primary user
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Slide24CarePortal Registration Process
Select a participating provider at your practice to validate your registration
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Slide25CarePortal Registration Process
Review your registration information and submit your registration requestUser will receive a confirmation email to verify registration
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Slide26CarePortal Registration Process
Adding new Ordering Providers to AccountSame Option Available for Rendering Facilities
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Slide27CarePortal Registration Process
Adding additional Users to your AccountManaged by Primary AccountAllows multiple users to reference same Order HistorySimilar to initial registration page
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Slide28Submitting Prior Authorization Online
Step 1: Log onto the portal HIPAA Disclosure Agreement must be accepted to loginStep 2: Home page is displayed. Click on ‘Authorization Request’
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Slide29Submitting 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.
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Slide30Submitting Prior Authorization Online
Step 4: Select and confirm the Ordering/Referring Physician
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Slide31Submitting Prior Authorization Online
Step 4: Once referring physicians have been added to your account, you may select a physician from the drop down menu.
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Slide32Submitting Prior Authorization Online
Step 5: Select and confirm the Rendering Facility
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Slide33Submitting Prior Authorization Online
Step 6: Fill in the required fields including requested Procedure Code(s) and Primary Diagnosis Code(s)
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Slide34Submitting Prior Authorization Online
Step 7: Select the patient’s signs and symptoms from the Clinical Criteria Tree that correspond with your requested procedureRequired for Automatic Approvals
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Slide35Submitting 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
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Slide36Submitting Prior Authorization Online
Step 9: Review submission screen with authorization number and status of the request (Pending or Approved)
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Reference Number
Slide37Reviewing a Pending or Completed Request
You will be notified by email 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
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Reference Number
Slide38Reviewing 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:
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Slide39Reviewing a Pending or Completed Request
Enter a date range, Member ID, or your case Reference Number:
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Slide40Member Eligibility Lookup
Enter member demographics and select “Search”If member is not found, please call (888) 223-4144
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Slide41CarePortal Tutorial
A video tutorial of the CarePortal and the Authorization process is available at www.caretocare.com
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Slide42Recap CarePortal Resources
Care to Care’s CarePortal, https://php.careportal.com, offers useful tools, information, and resources to better assist you in the prior authorization processView Clinical CriteriaView a Quick Reference Guide to ImagingDownload a Prior Authorization Request Fax FormRequest a Prior AuthorizationPerform a Status Check on an Authorization Request Only ordering physician’s office may submit an authorization request
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Slide43Thank you!Question and Answers