NIA - Interventional Pain Management and Spine Surgery

[Pages:28]NIA - Interventional Pain Management and Spine Surgery

Health Plan Training

NIA Program Agenda

? Introduction to Magellan/National Imaging Associates (NIA) ? Our Program

1. Authorization Process 2. Other Program Components 3. Provider Tools and Contact Information ? RadMD Demo ? Questions and Answers

NIA -- A Magellan Health Company 2

NIA Training Program

NIA -- A Magellan Health Company 3

NIA Highlights

NIA Facts

? Providing Client Solutions since 1995

? Magellan Acquisition (2006)

? Avon CT with ~500 National NIA Employees

? Business supported by two National Call Operational Centers

Industry Presence

? 54 Health Plan Clients serving 17M National Lives

? 10M Commercial; 1M Medicare; 6M Medicaid

? 26 states ? Doing business in

Hawai`i since 2006 serving 700,000 lives

Clinical

Leadership

? Strong panel of internal Clinical leaders ? client consultation; clinical framework

? Supplemented by broad panel of external clinical experts as consultants (for guidelines)

NCQA Certified & URAC Accredited

Product Portfolio

? Advanced Diagnostic Imaging

? Cardiac Solutions ? Radiation Oncology ? OB Ultrasound ? Pain Management ? Spine Surgery ? Sleep Management ? Emergency

Department, Provider Profiling & Practice Management Analysis

NIA--A Magellan Health Company 4

Why a Pain Management Product?

? More than 26 million Americans between the ages of 20-64 experience frequent back pain.

? Back pain is the 2nd most common neurological ailment in the US.

? Rising Risk Factors: ? Obesity ? Aging Population ? Physical Inactivity

? Back pain is the leading cause of disability in Americans under 45 years old.

NIA -- A Magellan Health Company 5

Why a Pain Management Product?

? NIA estimates that 20 percent of epidural injections, 18 percent of facet joint injections, and 30 percent of facet neurolysis procedures are possibly inappropriate.

? NIA's review of national data shows that up to 30 percent of fusions could be replaced with a less invasive procedure

NIA -- A Magellan Health Company 6

NIA's Precertification Program

Effective 1/1/2014

Procedures Requiring Precertification

? Outpatient/Office Interventional Pain Management-Spine (Spinal Epidural Injections, Facet Joint Injections, Facet Joint Denervation/Neurolysis)

? Inpatient and Outpatient Lumbar Spine Surgery ? (Lumbar Microdiscectomy, Lumbar Decompression, Lumbar Spine Fusion (Arthrodesis))

Excluded from Program: Procedures Performed in the Following Settings:

? Interventional Pain Management Hospital Inpatient Observation Room Emergency Room/Urgent Care Facility

? Lumbar Spine Surgery Emergency Surgery ? admitted via the Emergency Room

NIA -- A Magellan Health Company 7

List of CPT Procedure Codes Requiring Precertification

? Review Claims/Utilization Review Matrix to determine CPT codes managed by NIA

? CPT Codes and their Allowable Billable Groupings

? Located on RadMD ? Defer to Health Plan Policies for Procedures

not on Claims/Utilization Review Matrix

NIA -- A Magellan Health Company 8

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