avera health plans health plans is now partnered with carecore national to provide quality support...

P R O V I D E R O V E R V I E W

Avera Health PlansIn Partnership with CareCore National

Advanced Outpatient Imaging Changes for July 1, 2012

Avera Health Plans is now partnered with CareCore National to provide quality support in managing prior authorization for

outpatient radiology services, effective July 1, 2012 for services rendered on or after July 1, 2012.

CareCore National is a nationally recognized, physician founded Healthcare Solutions services corporation.

CareCore is URAC accredited, NCQA certified and Cybertrust Secured.

CareCore has the industry’s most extensive and current set of evidence-based specialty criteria.

Through CareCore’s established reputation for quality leadership and excellent customer service, they are the largest and fastest growing benefits management firm in the U.S.

Who is CareCore National?

Impacts members enrolled in:

• Avera Health Plans fully insured

• Avera MyPlan individual health insurance

• Avera employee health insurance plans

When reviewing the Avera Health Plans member ID card,

look at their Group Number.

Group Numbers Starting With:

•SD, IA and NE = Fully Insured

•IND or SING = Avera MyPlan

•AAH = Avera Employees

Members that Require Prior Authorization

The ordering physician/designee* is responsible for obtaining the authorization via:

Phone: 1 (866) 668-8295

- or -

Online:: www.CareCoreNational.com

CareCore National Call Center Hours:7 a.m. to 7 p.m. CT, Monday through Friday.

Website is available 24/7.

* A designee may be a member of the ordering physician’s office staff.

Prior Authorization Responsibility

•CT/CTA•MRI/MRA•PET Scan•Nuclear Cardiology•Nuclear Medicine

A full listing of imaging procedures and codes that will require prior authorization can be found on our website, www.AveraHealthPlans.com on the provider login page.

Avera Health Plans’ Advanced Outpatient Imaging Prior Authorizations Will Include:

Modalities Requiring Prior Authorization

Prior authorizations are required in all places of service except when the procedure is rendered:

• In an Emergency Room (place of service = 23) • In an Inpatient Hospital setting (place of service = 21).

Place of Service and Prior Authorizations

Physician evaluates clinical problem and determines an advanced imaging study is warranted that requires a prior authorization.

Physician seeks prior authorization request:

- Online

- Phone

Clinical Review Nurse will assess complete clinical information against Evidence Based Specialty Criteria.

Physician reviews case and a determination based on medical necessity is made.

Approval or case is sent for further review by

Medical Director.

Clinical personnel will review history and findings against evidence based criteria.

Prior Authorization Process

Case Numbers• A case number is assigned to EVERY request. • Case numbers are used for reference purposes only and

are not valid for claim payment. • The format is a 10-digit numeric value.

• Example: 1004567890

Authorization/Determination Numbers• A determination number is assigned to every case upon

completion of the review.• Authorization numbers are used systematically to validate

claim payment.• The format is an alpha code followed by numeric values and

the CPT code. • Example : A012345678-70450

Prior Authorization Details

Authorizations are valid 45 calendar days from the date of approval.

An approval date is the date the case is approved.

Most authorizations will be immediate (by phone or online).

NOTE: If further review is needed, CareCore has two business days to make medical necessity determination.

Prior Authorization Details

At any point in the case management process, the ordering physician may request to speak to a CareCore National Medical Director.

Call: 1 (866) 668-8295

Follow prompts.

Prior Authorization Details

• Cases not consistent with evidence-based criteria may not be certified.

• Both the provider and the patient will be notified by letter of cases not certified.

• Letters of noncertification will include the guidelines for the appeals process.

For questions or concerns around appeals, contact Avera Health Plans Service Center at (605) 322-4545 or toll-free at 1 (888) 322-2115.

Noncertification Determination

Noncertification Determination

Reconsiderations

Ordering physicians may request a reconsideration within 14 business days of determination by calling CareCore at 1 (866) 668-8295.

Please include additional clinical information that may need to be considered.

Noncertification Determination

AppealsAn ordering physician or member can initiate an appeal by contacting Avera Health Plans:

Email: ahpccnappeals@avera.org

Mail:Complaint and Appeals CoordinatorAvera Health Plans3816 S. Elmwood Ave, Suite 100Sioux Falls, SD 57106

Fax: 1 (800) 269-8561

More detailed instructions are included in the determination letter.

If the CPT® code for the authorized procedure differs from the code for the rendered procedure, the ordering or rendering provider is required to contact CareCore National at 1 (866) 668-8295 and select Customer Service to modify the request.

Please note that clinical documentation to support the change will be required.

• Change in modality• Adding contrast agents• Addition of contiguous body parts

You have up to two business days from the date of service to request a modification.

Updating Existing Authorization

Urgent requests must be made by phone only.

Urgent Prior Authorization Requests

To initiate an urgent prior authorization request, please call CareCore at 1 (866) 668-8295* and follow the prompts. You must state that the request is clinically urgent.

*Same as prior authorization phone number

• Clinically urgent cases will be reviewed and a determination will be made within three hours after CareCore National receives the required clinical information.

• Urgent requests may be initiated by the ordering physician and/or the designee.

CareCore National Web Portal Access

Referring Physicians•Initiate Authorizations•View Authorization status•Access reference material•Information and tutorials

Rendering Providers•Eligibility lookup•View Authorization status•Access reference material•Information and tutorials

www.CareCoreNational.com

Access Authorization Details Online

Online Prior Authorization RequestTo submit a prior authorization request or access authorization details online, first time users will need to register on the Provider Web Portal.

Provider Online Registration

Provider Online Registration

Provider Online Registration

Provider Online Registration

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xxx

Provider Online Registration

Provider Web Portal

Prior Authorization Online RequestReferring providers can submit a prior authorization request online by logging into the Provider Web Portal and selecting “Request a clinical certification.”

866-665-8341

Prior Authorization Online Request

Below is a sample of the Provider Portal view.

Referring Provider Access

Rendering providers can verify the status of an existing prior authorization request. Information needed for a search:

• Provider ID or Tax ID• Patient ID and Date of Birth or Authorization Number or

Case NumberOr Call 1 (866)-668-8295

Rendering Provider Access

Rendering Provider Access

Physicians may review the CareCore Evidence Based Guidelines at any time.

The Evidence Based Guidelines used in rendering medical necessity

decisions is posted publicly at www.CareCoreNational.com.

CareCore National Clinical Criteria

Avera Health Plans online resources which includes a link to CareCore’s website.

Additional Information

Resources found on Avera Health Plans Website:

www.AveraHealthPlans.com and click Provider Login

CareCore National Website Link

Reference Guide

Quick Access Phone Reference Sheet

Quick Access Online Reference Sheet

Frequently Asked Questions Document

Additional Information

Additional Information

Questions?