Changes to Blue Care Network Prior Authorization of ......• BCN Advantage appeals are handled by Blue Care Network • Appeal information will be included in the denial letter Appeals:

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Changes to Blue Care Network Prior Authorization of

Outpatient Therapy and Physical Medicine Services

2

Learning objectives

• Changes to BCN Prior Authorization of Outpatient Therapy and Physical Medicine services

• Registration and web portal navigation

• Reference Guide

• corePath Review

• BCN migration from Landmark Legacy to CareCore National Platform

Implementation Information:

• Authorization requests need to be submitted on the eviCore platform

beginning May 27, 2019 this includes all new and retro requests.

• Please note: The eviCore healthcare provider portal from web-DENIS

will not be accessible until May 31, however the eviCore portal can be

accessed directly at www.evicore.com starting May 27.

http://www.evicore.com/

Training Agenda

3

1. Prior Authorization Process

Program Scope

corePATH

Clinical Worksheets

Outcomes and Timeframes

2. Web Portal Services

Register for an Account

3. Case Initiation

corePATH specific questions

4. Provider Resources

5. Important Tips

6. Provider Performance Summary and Categorization

4

Musculoskeletal Management

Prior Authorization Process

5

OT/PT Current Effective 06/01/2019 with Web portal and phone submissions to start 5/27/2019

Referral Required Eliminated

Submission Method Web and Fax Web/Phone/Fax

1. Waiver visits eliminated

2. Category A provider - authorization of 'X' visits over an approved period with

minimal clinical information collected

3. Category B and C providers will submit clinical information at the initial request

which will be reviewed to determine medical necessity

Resources Landmark Connect www.eviCore.com or SSO through web-DENIS beginning 6/01/2019

Categorization Not impacted

Call eviCore or schedule a Clinical Consultation through the eviCore.com website

for cases initiated 5/27/2019 and beyond (Cases with authorization starting with

A). Call Lankmark to schedule P2P for existing LM cases

**If more visits are needed on a current auth in the LM system, go to the eviCore

portal to build a new case

Commercial: 1st and 2nd level appeal through LM Commercial: 1ST AND 2ND level appeal fax to Appeals fax at eviCore

Medicare: appeal through HP Medicare: Appeal through HP

Functional Outcome

MeasuresRevised PSFS

Condition specific functional outcome measures as specified within the clinical

collection process

Re-eval code New referral submitted to LM Submitted through clinical pathway

Date extension Requested through phone or fax Requested through phone or web, no change in rules

Coordination of benefits

amongst disciplinesCall Landmark Customer Service Call eviCore to coordinate benefits

Prior Authorization Process for BCN

Waiver Visits Category dependent

P2P Call Landmark

Appeals

6

Prior Authorization Process for BCN

Changes to benefits, benefit

dates, changing from minor

to major diagnosis

Call Landmark Customer Service Call eviCore to make changes to benefits

Retrospective Review

Retro requests must be submitted within 730

calendar days (2 years) following the date of

service

Retro requests must be submitted within 730 calendar days (2 years) following

the date of service

ST Current Effective 06/01/2019 with Web portal and phone submissions to start 5/27/2019

Referral Required Eliminated

Submission Method Fax Web/Phone/Fax

Waiver Visits N/A N/A

Resources Landmark Connect www.eviCore.com

P2P Call Landmark for existing casesWeb/phone to eviCore for cases initiated 5/27/2019 (Cases with authorization

starting with A)

Commercial: 1ST AND 2ND level appeal fax to Appeals fax at eviCore

Medicare: Appeal through HP

Appeals

OT/PT Current Effective 06/01/2019 with Web portal and phone submissions to start 5/27/2019

7

Program scope:

Prior authorization by eviCore

does NOT apply to services performed in the following

settings:

• Emergency room

• Inpatient

• In home care

• Skilled Nursing Facility

• Physical Therapy

• Occupational Therapy

• Speech Therapy

• Physical Medicine services performed by

Chiropractors* (for BCN HMO beneficiaries only)

Prior Authorization applies to services that are:

• Outpatient

Prior Authorization is Required for:

Prior Authorization by eviCore

Applies to:

• BCN HMO (Commercial)

• BCN Advantage (Medicare)

8

When to contact BCN

eviCore does not manage therapy services for patients receiving therapy with a diagnosis of Autism, specifically

codes F84.0, F84.5, F84.8, F84.9

Please contact BCN at 1-800-392-2512 for authorization requirements

eviCore does not manage therapy services for patients in Skilled Nursing Facilities

Please submit your request through the eReferral system or contact BCN at 1-800-392-2512

eviCore does not manage authorizations for Stand-alone orthotic splint


eviCore does not manage authorizations for Stand-alone massage therapy


9

Clinical Review Process

Easy for

providers

and staff

START

Methods of Intake

Therapist

review

Predictive

Intelligence/clinical

decision support

Appropriate

decision

Peer to

peer

Real-time decision with web

10

Needed Information

Member

Member ID

Member name

Date of birth

(DOB)

Rendering Facility

Facility name

National provider identifier (NPI)

*Tax identification number (TIN) – not

preferred

Street address

Supporting Clinical

Patient’s clinical presentation.

Diagnosis Codes.

Disease-Specific Clinical Information.

Patient’s intended treatment plan

Refer to the therapy specific Clinical Worksheets for the treatment being requested

Clinical Worksheets are found a www.eviCore.com

Requesting Provider

Typically same as Rendering

Facility for outpatient

PT/OT/ST requests


© eviCore healthcare. All Rights Reserved.

This presentation contains CONFIDENTIAL and PROPRIETARY information.

Focused on the patient: Authorization

strategy emphasizes the unique

attributes of a patient’s condition and

any associated complexities

Streamlined for providers: Providers

will experience a simplified and

consistent prior authorization process

that requires only key clinical

information

Condition-specific approvals: Visits

allocated in accordance with condition

severity / complexity, functional loss,

and confirmation that care is

progressing as planned

Therapy corePath

Evidence-based, condition-specific approach

11

12

Functional Status Initial vs Follow-Up

• Function-based – incorporates clinical, social, ADL factors

• Validated assessments – objective comparison

• Clinical factors that identify more complex cases based on key clinicals, chronicity

• Patient severity and complexity established at entry point

Initial Requests:

Follow-Up Requests:

• Re-statement of functional status

• Focus on progress and effectiveness of treatment – ‘dynamic assessment’

• Identify progress – attestation plus functional scale change

• Identify reasons for lack of progress – compliance, re-injury, exacerbation, etc.

13

Clinical Information Worksheets

• The clinical worksheets are therapy specific and designed to assist with the submission of patient and

provider information for medical necessity review

• Worksheets should be used as a guide for questions the therapist will be prompted to answer when

completing the online requests

• These worksheets should be completed by the provider during the initial consultation and treatment

planning, collecting the clinical information to allow for ease of submission

• Worksheets are available on the eviCore website and are therapy-specific to the treatment request

https://www.evicore.com/provider/online-forms

https://www.evicore.com/provider/online-forms

14

Sample MSK corePathSM Forms

Worksheets for the following

conditions are already available

using the CorePath approach:

• PT/OT MSK Conditions

• PT Neurodevelopmental

• OT Neurodevelopmental

**Other conditions will utilize former pathways

15

Prior Authorization Outcomes

• If a real time approval is not granted, requests will be processed within

3 business days after receipt of all necessary clinical information

• Urgent requests will be processed within 24 hours of receipt of all

clinical information; a final determination will be made no later than 72

hours of receipt of request

Approved Requests:

• Faxed to ordering provider

• Mailed to member

• Information can be printed on demand from the eviCore healthcare

Web Portal

Delivery:

16

Prior Authorization Outcomes

• Communication of denial determination

• Communication of the rationale for the denial

• How to request a Peer Review

Denied Requests:

• Faxed to the ordering provider

• Mailed to the member

• Information can be printed on demand from the eviCore

healthcare Web Portal

Delivery:

• Providers are able to request a pre-decision consultation

with an eviCore therapist for cases involving Medicare

patients

• Clinical consultations are permitted for denied Commercial

cases

Clinical Consultation:

• Commercial appeals will be handled by eviCore

• Member appeals are handled by Blue Care Network

• BCN Advantage appeals are handled by Blue Care

Network

• Appeal information will be included in the denial letter

Appeals:

17

Special Circumstances

• Retro requests must be submitted within 730 calendar days (2 years) following

the date of service. Requests submitted after 730 days will be administratively

denied

• Retro requests are reviewed for medical necessity. Turnaround time on a retro

request is 14 calendar days

Retrospective Requests

18

Web Portal Services

© eviCore healthcare. All Rights Reserved.This presentation contains CONFIDENTIAL and PROPRIETARY information. 19

WEB

The eviCore online portal is the quickest, most efficient way to request prior authorization and

check authorization status and is available 24/7. By visiting www.eviCore.com providers can

spend their time where it matters most — with their patients!

Or by phone:

855-774-1317 7:00 a.m. to 7:00p.m.Monday - Friday


© eviCore healthcare. All Rights Reserved.This presentation contains CONFIDENTIAL and PROPRIETARY information.

Portal Compatibility

20

The eviCore.com website is compatible with the following web browsers:

• Google Chrome

• Mozilla Firefox

• Internet Explorer 9, 10, and 11

You may need to disable pop-up blockers to access the site. For information on how to disable pop-up blockers for any of these web browsers, please refer to our Disabling Pop-Up Blockers guide.

../Disabling Pop-up Blockers.pdf


eviCore healthcare website

• Login or Register

• Point web browser to evicore.com


Creating An Account

22

To create a new account, click Register.


Creating An Account

23

Select a Default Portal, and complete the registration form.


Creating An Account

24

Review information provided, and click “Submit Registration.”


User Registration-Continued

25

Accept the Terms and Conditions, and click “Submit.”


Create a Password

26

Uppercase letters

Lowercase letters

Numbers

Characters (e.g. ! ? *

Your password must be at least (8) characters long and contain the following:


Account Log-In

27

To log-in to your account, enter your User ID and Password. Agree to the HIPAA Disclosure, and click “Login.”


Welcome Screen

28

• Providers will need to be added to your account prior to case submission. Click the “Manage Account” tab to add provider information.

• Note: You can access the MedSolutions Portal at any time without having to provide additional log-in information. Click the MedSolutions Portal button on the top right corner to seamlessly toggle back and forth between the two portals.


Add Practitioners

29

Click the “Add Provider” button.


Add Practitioners

30

Enter the Provider’s NPI, State, and Zip Code to search for the provider record to add to your account. You are able to add multiple Providers to your account.


Adding Practitioners

31

Select the matching record based upon your search criteria


Manage Your Account

32

• Once you have selected a practitioner, your registration will be completed. You can then access the “Manage Your Account” tab to make any necessary updates or changes.

• You can also click “Add Another Practitioner” to add another provider to your account.

© eviCore healthcare. All Rights Reserved.This presentation contains CONFIDENTIAL and PROPRIETARY information. 33

Certification Summary

• CareCore National Portal now includes a Certification Summary tab, to better track your recently submitted cases.

• The work list can also be filtered - as seen above.

34

Case Initiation

Initiating A Case

35

• Choose “request a clinical certification/procedure” to begin a new case

request.

Select Program

36

Select the Program for your certification.


Select Provider

37

Select the Practitioner/Group for whom you want to build a case.


Select Health Plan

38

Choose the appropriate Health Plan for the case request. If the health plan does not populate, please contact the plan at the number found on the member’s identification card.

Once the plan is chosen, please select the provider address in the next drop down box.


Contact Information

39

Enter the Provider’s name and appropriate information for the point of contact individual.


Treatment Start Date

40

Enter the Requested Start Date of the services


Member Information

41

Enter the member information including the Patient ID number, date of birth, and patient’s last name. Click “Eligibility Lookup.”


Clinical Details

42

Select the CPT and Diagnosis codes.


Verify Service Selection

43

Click continue to confirm your selection.


Site Selection

44

Select the specific site where the testing/treatment will be performed.


Site Selection

45

This page allows you to enter an email address for a facility representative.


Clinical Certification

46

• Verify all information entered and make any needed changes prior to moving into the clinical collection phase of the prior authorization process.

• You will not have the opportunity to make changes after that point.


Contact Information

47

Select an Urgency Indicator and Upload your patient’s relevant

medical records that support your request.

If your request is urgent select No, if the case is standard select

Yes.

You can upload up to FIVE documents in .doc, .docx, or .pdf format. Your case will only be considered Urgent if there is a successful upload.


Medical Review

48

If additional information is required, you will have the option to either free hand text in the additional information box, or you can mark Yes to additional info and click submit to bring you to

the upload documentation page. Providing clinical information via the web is the quickest, most efficient method.


Clinical Certification Pathway

49

Once you have entered the clinical collection phase of the case process, you can save the information and return within two business days to complete.

Sample Therapy corePathSM Pathway

Initial Requests

50

• Case Related Questions:

• Identify new care vs. continuing care based on treatment area, not time

• Identify primary area of treatment

• First indicator of complexity – second unrelated treatment area

1

2

3


Initial Requests

51


Initial Requests

52


Initial Requests, continued….

53

• Initial Clinical Questions:

• Enter functional score, if available• Oswestry Index• Neck Disability Index• LEFS• Dash / QuickDASH• HOOS JR/KOOS JR

• Incorporates ROM, Strength, Pain, etc.

• Complexity: • Neural signs• Chronicity

4

5

6

High Potential for Immediate Approval When Pathway is

Completed!


Initial Requests

54


Initial Requests

55


Attestation

56

Acknowledge the Clinical Certification statements, and hit “Submit Case.”


Follow-Up Request

57

• Follow-Up Clinical Questions:

• Current and Previous Functional Score

• Complexity Question –Neural Signs

• Progresso Validated scores have MCD

(minimal clinical difference) as progress indicator

o Clinical Assessment

1

2

3

High Potential for Immediate Approval When Pathway is

Completed!


Follow-Up Request – Lack of Progress Identified

58

• Lack of Progress: • Categories of explanations• Used in algorithm to determine care• Future, additional pathway to identify details


Approval

59

Once the clinical pathway questions are completed and

the answers have met the clinical criteria, an approval

will be issued.

Print the screen and store in the patient’s file.

60

Medical Review

Once the clinical pathway

questions are completed and the

case has not meet clinical review.

The status will reflect pending

and at the top “Your case has

been sent to Medical Review”.

Print the screen and store in the

patient’s file.

Building Additional Cases

61

Once a case has been submitted for clinical certification, you can return to the Main

Menu, resume an in-progress request, or start a new request. You can indicate if any

of the previous case information will be needed for the new request.

Authorization look up

62

Select Search by Authorization Number/NPI. Enter the provider’s NPI and authorization or

case number. Select Search.

You can also search for an authorization by Member Information, and enter the health

plan, Provider NPI, patient’s ID number, and patient’s date of birth.

63

Search Results and Electronic Clinical Upload Feature

Eligibility Look Up

64

You may also confirm the patient’s eligibility by selecting the Eligibility Lookup tab.

65

Provider Resources

66

• You can access important tools and resources at www.evicore.com.

• Select the Resources to view Clinical Guidelines, Online Forms, and more.

Online Resources


67

• Select the Resources, then select the Clinical Worksheets – next, select the

program (Musculoskeletal: Therapies) then you type in the health plan to view

the Clinical Worksheet choices.

Online Resources

Quick Reference Tool

68

Access health plan specific contact information at www.evicore.com by clicking the resources

tab then select Find Contact Information, under the Learn How to section. Simply select

Health Plan and Solution to populate the contact phone and fax numbers as well as the

appropriate legacy portal to utilize for case requests.


Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Prior Authorization Call Center

69

7:00 AM - 7:00 PM (EST): 855-774-1317

• Obtain prior authorization or check the status of an existing case

• Discuss questions regarding authorizations and case decisions

• Change facility or CPT Code(s) on an existing case

Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Web-Based Services

70

evicore.com

To speak with a Web Specialist, call (800) 646-0418 (Option #2) or email

[email protected].

• Request authorizations and check case status online – 24/7

• Pause/Start feature to complete initiated cases

• Upload electronic PDF/word clinical documents

mailto:[email protected]

Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Client Provider Operations

71

To reach eviCore Client Services, call (800) 646-0418 (Option #4) or email

[email protected]

• Eligibility issues (member, rendering facility, and/or ordering physician)

• Questions regarding accuracy assessment, accreditation, and/or

credentialing

• Issues experienced during case creation

• Request for an authorization to be resent to the health plan


Client Provider

Operations

Pre-Certification

Call Center

Web-Based

Services

Documents

Provider Resources: Provider Resource Page

72

Blue Care Network’s Provider Resource Page

www.eviCore.com/healthplan/BCN

• Provider Orientation Presentation

• Quick Reference Guide

• eviCore clinical guidelines

• FAQ documents and announcement letters

You can obtain a copy of this presentation on the implementation site listed above. If you are

unable to locate a copy of the presentation, please contact the Client Provider Operations

team at [email protected].

http://www.evicore.com/healthplan/BCN


73

Thank you

Thank you for attending today’s webinar!

• BCN will be sending out evaluation to the email that you registered with.

• An email with the materials will be sent at the conclusion of the meeting.

• The remainder of the training materials include the following information:

• Important Tips

• Provider Performance Summary and Categorization

• How to access the eviCore Provider Portal via web-DENIS

• Additional info/links/link to webinar

• FAQs

• Communications

74

Important Tips

75

• The therapist should always complete the initial evaluation PRIOR TO submitting a request for prior

authorization

• Submit your request to eviCore within 7 days of the requested start date

• Submission by web or phone increases the chance of a real time approval for the initial and second request

• Requests that report lack of progress will be reviewed by a therapist

• A therapist will review all requests after the second request – from the 3rd request on there will be no real

time approval available

• In order to receive an appropriate decision to best treat the member’s condition, it is important that all questions

are answered

• You may request additional visits as early as 7 days prior to the requested start date

• Requests should include current clinical information

Important Tips

Turn Around Time

76

• Web and phone cases may be eligible for a real time approval

• If not approved in real time, cases may take up to 3 business days once all clinical information is

received

• Cases with no or incomplete clinical information may take up to 14 days as allowable by CMS

• eviCore is required to reach out to the provider in multiple ways to obtain the necessary clinical

information

• eviCore will send fax/call to request information

• Once we receive the information, the case will be reviewed

• If clinical has not been received by the 10th day, the case may be denied

Important Tips

Ask yourself….

77

• Why does the member require therapy?

• Can the services provided be performed by the patient or caregiver as part of a home management program? If

no, explain why they can’t be

• Can the services provided be performed in a community based program? If no, explain

• Are there specific safety concerns present supporting the need for services ONLY by a therapist?

• Does the member require skilled maintenance therapy?

• Establish or design of a maintenance program by a qualified therapist,

• Instruct the beneficiary or appropriate caregiver to carryout the maintenance program,

• Periodically reevaluate the beneficiary and update the maintenance program

• Are there social factors present that complicate the member’s condition? If yes, has there been investigation as

to whether there are additional services are available to support the member?

• Is therapy being used as a substitute for something else?

Medical Necessity

78

Provider Performance Summary

and Categorization

Transparency and Collaboration

Provider Performance Summary (PPS)

79

Insight into your practice patterns and how

they compare with your network peers

Timely access to information to monitor

performance over time and by condition

Patient visits are adjusted for factors that

account for variation in visit usage

“Your Value” data points drill down to the paid

claim data used to build your practice profiles

BCN Provider Profiling

Provider Performance Summary (PPS)

80

• Facilities: PTs in outpatient therapy centers and hospitals are profiled based on the

organization NPI.

• Independent PTs: IPTs are profiled based on their provider group affiliation (BCN group

ID/organization NPI).

• Physicians: Physician delivered/supervised physical therapy (MD/DO) practices are

profiled based on the physician’s individual NPI.

BCN Profiling Data

• BCN HMO (commercial) claims

• BCN Advantage claims

81

Accessing Your PPS Dashboard in eviCore’s Provider Portal

Web-DENIS Users

eviCore direct login users

• Select Practitioner Performance Summary

• Select the health plan (Blue Care Network)

• The PPS is available for the NPI you selected in web-DENIS

• Click View PPS

• Select Practitioner Performance Summary in the menu

• Select the health plan (Blue Care Network)

• Select a provider that you have added to your web user account

• Click View PPS

82

Your PPS Security Code

Mailed every six months to enable drill down to claims data

Your risk-adjusted visits per episode (RAVE) establishes your category

83

• Category A practices have RAVEs up to the BCN 50th percentile

• Category B practices have RAVEs from the BCN 50th to 75th percentile

• Category C practices have RAVEs above the BCN 75th percentile

Your Physical Therapy Utilization Management Category

Category A Providers Category B & C Providers

• PT services require pre-

authorization.

• Request authorization within 7

days of the patient’s initial visit.

• eviCore will issue an immediate

approval for PT visits up to the

patient’s maximum benefit for

you to provide medically

necessary care.

• PT services require pre-

authorization.

• Request authorization within 7

days of the patient’s initial visit.

• eviCore will approve visits in

accordance with condition

severity/complexity, functional

loss and confirmation that care

is progressing as planned.

84

Independent physical therapists are profiled as a group. When requesting authorization,

search for the rendering site by the group’s NPI.

Outpatient therapy centers and hospitals follow the pre-authorization process for their

assigned category (A/B/C) for both PT and OT. When requesting authorization, search

for the rendering site by the facility NPI.

Therapists who aren’t assigned a category follow eviCore’s standard care management

program:

• PTs who didn’t have at least 10 treatment episodes in the PPS reporting period

• PTs who are added as new in-network providers

• Independent occupational therapists, speech therapists, podiatrists and chiropractors

who perform physical medicine services

The PT network is assessed every six months.

• Your assigned category is posted in the PPS portal 30 – 60 days before the effective

date.

Important Utilization Management Category Information

85

Accessing Your Utilization Management Category

• Click on the UM Category tab in the PPS portal

• Online reconsiderations requests are available within the 15-day period

• Once you initiate a reconsideration review, export your patient list and send eviCore

your supporting documentation within 15 additional days

UM categories are available online

86

Online Reconsideration Request Now Available for BCN

87

Reconsideration Reviews

If you believe circumstances adversely affected utilization data, you may request

reconsideration within 15 days of eviCore’s notification.

You’ll be required to provide information to support an adjustment to your visits per episode

for the following circumstances:

Outliers

• An outlier is a patient who requires higher intensity and/duration of services due to

medical complexity that affects the members response to therapy

• All outliers must be identified at the time information is submitted

Additional episodes of care

• When a patient had surgery for the involved condition after treatment was started

• When a patient had a significant event, such as - stroke, amputation etc

All recommendations made by eviCore are sent to the health plan for review and approval.

Your reconsideration decision is final.

88

PPS & Categorization Overview by Health Plan

Blue Cross Blue Shield

Michigan

Blue Care Network

Hospitals & OPTs Facility NPI Facility NPI

IPTs Individual NPI Group NPI

Physicians n/a MD/DO individual NPI

Category A Below 80% peer average

Streamlined authorization

Below 50th percentile

Streamlined authorization

Category B80% - 120% peer average

corePath

50th to 75th percentile

corePath

Category C> 120% peer average

corePath

> 75th percentile

corePath

Disaffiliation policy Yes No

Category notices February | August June | December

Recon time limit 15 days 15 days

Category effective April | October February | August

PT Clinical Pathway for UM Category A Providers

89

Streamlined process & real-time authorization for web requests


90

Musculoskeletal condition clinical information


91

Outcome measures

92

How to access eviCore Provider Portal

via web-DENIS

93

1 – Visit bcbsm.com/providers.

2 - Log in to Provider Secured

Services using your user name

and password. (Be sure to click

Provider first.)

3 – Click LOGIN.

How to access the eviCore healthcare provider

portal from web-DENIS

94

4 – Click web-DENIS on the Provider Secured Services landing page.



95

5 – Click

Subscriber Info,

on the Welcome

to web-DENIS

landing page.

6 – Click

Eligibility/Coverage/COB.



96



7 – Enter the

member’s contract

number.

8 – Click Blue Care Network.

9 – Click Enter.

97



10 – Click Authorizations and Referrals,

on the appropriate member line.

98



11 – Enter your NPI.

12 – Click Enter.

You’ll enter the eviCore healthcare provider portal.