Spine Management and Prior Authorization

Spine Management and Prior Authorization
Referral, Notification, and Authorization—Authorization
Spine Management and Prior Authorization
Unless otherwise specified, information in this policy does not apply to members with the Choice or Choice Plus products offered through Passport
ConnectSM. For UnitedHealthcare’s related policies/procedures, please go to www.UnitedHealthcareOnline.com or call 800-708-4414.
Overview
Harvard Pilgrim’s Spine Management and Prior Authorization services are managed through an arrangement with
National Imaging Associates (NIA).
Non-emergent interventional pain management procedures and spine surgery services listed below are managed
through the Spine Management and Prior Authorization program:
• Epidural injections
• Facet joint injections
• Facet neurolysis
• Lumbar fusion — single and multiple level
• Lumbar decompression
• Lumbar microdiscectomy
•Artificial Cervical Disc Replacement — single level
•Effective April 01, 2017, non-emergent Artificial Cervical Disc Replacement –– 2 levels
Emergent procedures performed for members admitted through the hospital emergency room do not require prior
authorization.
National Imaging Associates
NIA is NCQA-certified and URAC-accredited, and has managed Harvard Pilgrim’s Outpatient Advanced Imaging Program
since 2010.
NIA has developed clinical guidelines that outline the key surgical treatments and clinical indications for common spinal
disorders; these guidelines are based on practice experiences, literature reviews, specialty criteria sets, expert opinions
from leading spine and neurosurgeon clinical leaders, and empirical data.
NIA’s Clinical Guidelines can be found on its website www.radmd.com, and are presented in a PDF file format that can
be printed for future reference.
Action Required—Ordering Provider
The ordering clinician is responsible for notifying NIA before scheduling listed outpatient interventional pain management procedures and non-emergent spine surgery services. Authorization from NIA can be requested
• on-line at www.radmd.com, or
• by telephone at 800-642-7543 (NIA’s Call Center hours of operation are Mon.–Fri., 8 a.m.–8 p.m.).
Ordering providers should refer to NIA’s website www.radmd.com/signup, for RadMD registration instructions.
Clinical indications and medical necessity of the planned procedure will be evaluated against NIA’s evidence-based
guideline algorithms. When NIA’s medical necessity criteria are not met, a board-certified NIA physician will contact
the ordering provider for a peer-to-peer conversation to obtain additional information and discuss potential treatment
alternatives.
•Authorization is not complete until consultation (if required) has been concluded and an approved authorization
transaction number has been issued.
•Failure to complete the authorization process will result in an administrative denial of the claim payment. Information Required
Ordering clinicians are responsible for providing clinical information relevant to request at the time of the call. The following information should be available:
• Ordering physician name, office phone, mailing address, fax number
• Office administrative or clinical contact name or direct line/extension number
• Patient’s name, date of birth and Harvard Pilgrim identification number
• Patient history, clinical diagnosis and relevant symptoms
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Referral, Notification, and Authorization—Authorization
Spinal Management and Prior Authorization (cont.)
•Date of onset and duration of back pain/symptoms
• Physical exam findings
•Results of prior diagnostic imaging
• Non-operative treatment modalities completed (e.g., physical therapy, epidural injections, chiropractic or osteopathic
manipulation, hot packs, massage, ice packs, medications)
• History of previous medical and surgical treatment
• Name and address of provider office or facility where requested service will be performed
• Valid, specific ICD-9/ICD-10 diagnosis code that represents the indications(s) for which the service is ordered, and CPT
code for requested procedure
Action Required—Servicing Provider
Servicing providers are responsible for confirming that the ordering clinician has completed the prior notification/authorization process (before providing services) by requiring evidence of an approved NIA transaction number.
• Procedures should be scheduled only when an approved NIA transaction number is verified.
• If a patient calls to schedule an appointment for a procedure that requires authorization, and does not have the
approved NIA transaction number, the patient should be directed back to the ordering clinician.
• If a provider/facility performs a procedure for which authorization was required but not obtained, the procedure will
not be reimbursed, and the member cannot be balance billed.
NIA Response
When the authorization process is completed, a transaction number will be given to the caller, and a confirmation fax
will be sent to the ordering clinician. NIA will also send written confirmation of approval and denial decisions to the
member.
If the request is approved, confirmation will also be faxed to the servicing provider. The approval will contain the following information:
• Approved transaction number (ex. NIV12345)
• Planned procedure
• Servicing provider
• Date of service, if known
Denial letters will contain information needed to assist the member in understanding the reason(s) for the denial, and
deciding whether or not to appeal the decision, including:
•The specific reason(s) for the denial, including clinical justification of the decision (consistent with generally accepted
standards of medical practice); discussion of the individual member’s presenting symptoms or condition, diagnosis, and
treatment interventions; and specific information upon which the adverse determination was based.
•The reason(s) that criteria were not met, including a reference to the benefit provision, guideline, protocol, or other
criterion on which the denial was based, and notification that the member can obtain a copy of the actual information on which the denial was based.
•Any alternative treatment options offered by Harvard Pilgrim.
•The date that written or electronic confirmation was sent.
•Instructions as to how the member and/or physician can obtain a copy of the criteria used to make the determination.
•A description of appeal rights, including the right to submit written comments, documents, or other information
relevant to the appeal; and an explanation of the appeal process including the right to member representation and
timeframes for deciding appeals.
Status Inquiry
Electronic
Servicing providers can use electronic channels to determine if authorization has been completed. Authorization status
and approved transaction numbers will be available to servicing providers through HPHConnect and NEHEN, usually
within three hours of a completed notification process. Alternatively, status and transaction numbers can be accessed
through NIA’s website, www.radmd.com.
• Detailed HPHConnect instructions are available at www.harvardpilgrim.org/providers. (Refer to the user guides at
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Referral, Notification, and Authorization—Authorization
Spinal Management and Prior Authorization (cont.)
HPHConnect/User Guides.)
• For NEHEN instructions, refer to your NEHEN documentation.
• Refer to NIA’s website, www.radmd.com, for RadMD registration information.
Phone Option
Providers may check the status of authorization requests by phone, 24 hours a day, 365 days a year, at 800-642-7543—
select option 2 from the main menu. This service is specifically for status inquiries only.
Notification Changes
NIA must be notified by telephone if any change to the original authorization occurs, such as a change to the procedure, a change to the servicing provider or a change to the date of service (if the new date of service exceeds the original date validity period). Records in HPHConnect, NEHEN and RadMD cannot be edited.
Billable CPT Codes
The table below contains the CPT-4 codes that NIA manages through Harvard Pilgrim Pilgrim’s Spine Management and
Prior Authorization Program. If an exam is billed under any one of the given codes for that grouping and an approved
transaction number has been issued within the date range validity period, the charge will be allowed. If a family of CPT
codes is not listed in this table, an exact match is required between the notified CPT code and the billed CPT code.
Authorized CPT Code
Description
Allowable Billed Groupings
62321
Cervical/Thoracic Interlaminar Epidural
62320, 62321, 64479
64479
Cervical/Thoracic Transforaminal Epidural
62320, 62321, 64479
62323
Lumbar/Sacral Interlaminar Epidural
62322, 62323, 64483
64483
Lumbar/Sacral Transforaminal Epidural
62322, 62323, 64483
64490
Cervical/Thoracic Facet Joint Block
64490
64493
Lumbar/Sacral Facet Joint Block
64493
64633
Cervical/Thoracic Facet Joint Radiofrequency Neurolysis
64633
64635
Lumbar/Sacral Facet Joint Radiofrequency
Neurolysis
64635
22612
Lumbar Fusion - Single Level**
22533, 22558, 22612, 22630, 22633
22614
Lumbar Fusion - Multiple Levels**
22533, 22558, 22612, 22630, 22633
63030
Lumbar Microdiscectomy
62380, 63030
63047
Lumbar Decompression
62380, 63030, 63005, 63012, 63017,
63042, 63047, 63056,
22856
Cervical Artificial Disc Replacement ––
Single Level
22856, 22861, 22864
22858
Cervical Artificial Disc Replacement ––
Two Levels
22858
**0375T is not a covered service and is not reimbursable
publication history
04/15/14
original documentation
07/25/14
added RI implementation pending regulatory approval information
05/15/15
added cervical disc replacement information, effective 07/01/15; removed 77003 (with 62310 or 62311) from coding grid; made administrative edits for clarity
12/15/16
updated billable CPT code table
03/15/17
added artificial cervical disc replacement –– single level; added effective 04/01/17, non-emergent artificial cervical disc replace
ment –– two levels; updated billable CPT code table; removed Rhode Island implementation pending regulatory approval
reference
05/12/17
deleted code 62311; added code 62323
06/15/17
updated billable CPT code table
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June 2017
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