Physical Medicine Prior Authorization - Quick Reference Guide for Providers Form

1 — Fidelis Care - Physical Medicine QRG (Revised 10/2021)

Fidelis Care Physical Medicine Prior Authorization Quick Reference Guide for Providers

Effective October 1, 2019 (Medicaid, Essential, CHP, and Qualified Health), October 1, 2021 (Medicare and Dual Advantage)

Beginning October 1, 2021, Fidelis Care will be expanding our partnership with National Imaging Associates, Inc. (NIA) to provide utilization management for outpatient rehabilitative and habilitative physical medicine services for Fidelis Care’s Medicare members. This expansion builds on Fidelis Care’s current prior authorization program for physical medicine services being provided to their Medicaid, Dual Advantage, Essential, CHP, and Qualified Health members. The program is consistent with industry-wide efforts ensuring that physical medicine services provided to our members are consistent with nationally recognized clinical guidelines.

The NIA outpatient rehabilitative and habilitative Physical Medicine Prior Authorization program began on October 1, 2019 for members with Medicaid, Essential, CHP, and Qualified Health plans and the Medicare and Dual Advantage programs will begin on October 1, 2021. The NIA Call Center will begin accepting prior authorization requests for Medicare members on September 20, 2021 for dates of service October 1, 2021 and beyond.

The NIA program is managed through Fidelis Care’s contractual relationships with providers who deliver outpatient therapy services. NIA conducts medical necessity reviews of requested services only.

Prior Authorization Providers must obtain prior authorization for the physical medicine procedures listed within 1 business day for outpatient services and 2 business days for home health service from the date these services were rendered.

Services Requiring Authorization: Outpatient Therapy Services for: • Physical Therapy
• Speech Therapy
• Occupational Therapy
The review is focused on therapy services performed in the following settings: • Outpatient Office
• Outpatient Hospital
• Home Health

2 — Fidelis Care - Physical Medicine QRG (Revised 09/2021)

Therapy provided in Hospital ER, Inpatient and Observation status, Acute Rehab Hospital Inpatient, and Skilled Nursing Facility Inpatient (POS 31 and 32) settings are excluded from this program.
• CPT codes billed for Physical, Occupational, and Speech Therapy for initial evaluations do not require an authorization for participating providers. All other billed codes even if performed on the same date as the initial evaluation date will require authorization prior to billing.

• Providers, such as home health providers, submitting claims using codes other than designated initial evaluation CPT Codes should submit their authorization request to NIA within 1 business day for the outpatient setting or 2 business days for the home health setting. In return, NIA will backdate the authorization to cover the initial evaluation and any services provided on that date of service.

Submitting Prior Authorization Requests
• Providers are encouraged to utilize www.RadMD.com to request prior authorization for Physical Medicine services. If a provider is unable to use RadMD, they may call
o Medicaid, Essential, CHP, & Qualified Health: ▪ 1-800-424-4952 o Medicare and Dual Advantage:
▪ 1-800-424-5390 Information Needed to Submit Prior Authorization Requests To expedite the prior authorization process, please have the appropriate information ready before logging into NIA’s website, www.RadMD.com or calling NIA’s call center.

▪ Name, address, and TIN of the facility that will be used for billing the service. ▪ Member name, ID number, and date of birth ▪ Requesting/Rendering Provider Type - PT, OT, ST ▪ Name of office or facility where the service will be performed ▪ Date of initial evaluation
▪ ICD-10 code(s) ▪ Details justifying therapy • Initial Evaluation or Re-evaluation findings • Past medical history • Patient symptoms • Prior treatment received for the same condition • Functional Outcome/Standardized Test Scores • Baseline functional status and Impairments • Objective tests and measures • Specific functional goals • Interventions to be utilized • Plan of Care/Treatment Plan

3 — Fidelis Care - Physical Medicine QRG (Revised 09/2021)

Website Access
▪ To get started, go to www.RadMD.com, click the New User button and submit a RadMD Application for New Account by selecting “Physical Medicine Practitioner.”
▪ You can request prior authorization at www.RadMD.com by clicking the “Request Physical Medicine” link which is a part of your main menu options.
▪ Additional services on an existing authorization can be requested using the “Initiate a Subsequent Request” link using RadMD. ▪ RadMD is available 24/7, except when maintenance is performed once every other week after business hours.
▪ Pended requests: If you are requesting prior authorizations through the NIA website and your request pends, you will receive a tracking number. You will then be required to submit additional clinical information to complete the process. ▪ Authorization’s status: You can check on the status of prior authorizations quickly and easily by using the “View Request Status” link on RadMD’s main menu. In addition to the ability to view clinical documentation received by NIA, users can view links to case- specific communication to include requests for additional information and determination letters. ▪ The “Track an Authorization” feature will allow users who did not submit the original request to view the status of an authorization, as well as upload clinical information.
This option is also available as a part of your main menu options using the “Search by Tracking Number” feature. A tracking number is required with this feature.

Telephone Access ▪ Call center hours of operation are Monday through Friday, 8 am to 8 pm EST. Prior authorizations may be requested by calling NIA at: 1-800-424-4952 (Medicaid, Essential, CHP, & Qualified Health) and 1-800-424-5390 (Medicare and Dual Advantage). ▪ If you have questions or need more information about this physical medicine prior authorization program, you may contact the NIA Provider Service Line at: 1-800-327-

641. Submitting Claims ▪ Please continue to submit claims to Fidelis Care as you currently do today.
     ▪ We strongly encourage electronic claims submission.

     Important Notes ▪ NIA will begin accepting authorization requests on September 20, 2021 for services rendered on or after October 1, 2021. ▪ The authorization number or request ID consists of at least 12 alpha-numeric characters (i.e., 12345CNY1234). ▪ Received after a determination has been made on a request ▪ Submitted with the claim ▪ Can be used to track an authorization in NIA’s system ▪ Tracking Number consists of at least 9 numeric digits (i.e. 123456789)
     ▪ Received prior to a determination being made on a request.

4 — Fidelis Care - Physical Medicine QRG (Revised 09/2021)

▪ Can be used to track an authorization in NIA’s system

▪ Clinical Guidelines: NIA issues authorizations in accordance with the NIA Clinical Guidelines and Milliman Care Guidelines for physical medicine. A link to these clinical guidelines can be found on www.RadMD.com under “Online Tools/Clinical Guidelines”. NIA Guidelines for physical medicine services are based on evidence-based research, generally accepted industry standards and best practice guidelines established by the corresponding national organizations. ▪ Complaints/Appeals: For prior authorization complaints/appeals, please call Fidelis Care or follow the instructions on your denial letter or Remittance Advice (RA). ▪ Member Eligibility: To verify member eligibility, including benefit information, please call the Provider/Customer Service line on the back of the member’s ID card. ▪ A prior authorization number is not a guarantee of payment. Whether the requested service is covered is subject to all of the terms and conditions of the member's benefit plan, including but not limited to, member eligibility, benefit coverage at the time services are provided and any pre-existing condition exclusions referenced in the member's benefit plan.
▪ Balance Billing: Payment will be denied for Physical Medicine procedures performed without a necessary prior authorization, and the member cannot be balance-billed for such services. ▪ Provider Relations Assistance: To educate your staff on NIA procedures and to assist you with any provider issues or concerns, contact your Fidelis Care or NIA Provider Relations Specialist.