Medical Specialty Solutions – Provider Training Guide Form

Fidelis Care Medical Specialty Solutions Provider Training Presented by: Seth Cohen PT, DPT

NIA Program Agenda Introduction to NIA Our Program Authorization Process Other Program Components Provider Tools and Contact Information RadMD Demo Questions and Answers 2

NIA Specialty National Footprint / Medicaid Experience 3 Since 1995 – delivering radiology benefits management solutions; one of the go-to care partners in industry. 77 health plans/markets – partnering with NIA for management of advanced and/or cardiac imaging solutions. 31.85M national lives – participating in an NIA RBM nationally.
Diverse populations – Medicaid, Exchanges, Medicare, Commercial, FEP, Provider Entities. 69 Medicaid plans/markets with NIA RBM solutions in place. 12.5M Medicaid lives – in addition to 3.9M Exchange and 2M Medicare Advantage lives participating in an NIA RBM program nationally.
National Footprint Medicaid/Medicare/Exchange Expertise/Insights URAC Accreditation & NCQA Certified Intensive Clinical Specialization & Breadth Specialized Physician Teams  160+ actively practicing, licensed, board- certified physicians  28 specialties and subspecialties 14M Commercial lives

4 NIA’s Prior Authorization Program  Fidelis Care will begin a prior authorization program through NIA for the management of outpatient imaging, cardiac, physical medicine, and radiation oncology services.  Program start date: October 1, 2021  Begin obtaining authorizations from NIA on September 20, 2021 via RadMD or Call Center for services rendered on or after October 1, 2021.  Medicare  Medicaid  Dual Advantage  Exchange  CHP  Qualified Health Plans Settings:  Office  Outpatient Hospital The Program Important Dates Procedures & Settings Included Membership Included Network  NIA will use the Fidelis Care network of In- office providers, Free- Standing Imaging Facilities (FSFs), and Hospitals to deliver outpatient imaging services to Fidelis Care’s members.   CT/CTA  CCTA  MRI/MRA  PET Scan  Myocardial Perfusion Imaging  MUGA Scan  Stress Echocardiography  Echocardiography

CT/CTA CCTA MRI/MRA PET Scan Myocardial Perfusion Imaging MUGA Scan Stress Echocardiography Echocardiography NIA’s Prior Authorization Program 5 Hospital Inpatient Observation Emergency Room Urgent Care Surgery Center Procedures Requiring Authorization Excluded from the Program Procedures Performed in the following Settings: Effective October 1, 2021: Any services rendered on and after October 1, 2021 will require authorization. Only non-emergent procedures performed in an outpatient setting require authorization with NIA.

List of CPT Procedure Codes Requiring Prior Authorization Review Claims/Utilization Review Matrix to determine CPT codes managed by NIA. CPT Codes and their Allowable Billable Groupings. Located on www.RadMD.com. Defer to Fidelis Care’s Policies for Procedures not on Claims/Utilization Review Matrix. 6 6

Prior Authorization Process Overview Ordering Physician is responsible for obtaining prior authorization. Algorithm Service Authorized Rendering Provider
ensures an authorization was obtained, then performs the service 7 Information evaluated via algorithm and medical records
or by Phone Submit Requests Online Through RadMD www.RadMD.com Recommendation to Rendering Providers: Do not schedule test until authorization is received

NIA’s Clinical Foundation & Review 8 Peer-to-Peer Discussion Clinical Review by NIA’s Specialty Clinicians Fax/Upload Clinical Information
(upon request) Clinical Algorithms collect pertinent information Clinical Guidelines Are the Foundation  Clinical guidelines were developed by practicing specialty physicians, through literature reviews and evidenced-based research. Guidelines are reviewed and mutually approved by the Plan and NIA Medical Officers and clinical experts.
Clinical Guidelines are available on www.RadMD.com  Algorithms are a branching structure that changes depending upon the answer to each question.  The member’s clinical information/medical record will be required for validation of clinical criteria before an approval can be made.  NIA has a specialized clinical team.  Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines.
 Our goal – ensure that members are receiving appropriate care.

Member and Clinical Information Required for Authorization 9 Clinical Information General  Includes: ordering physician information, member information, rendering provider information, requested examination, etc.  Includes clinical information that will justify examination, symptoms and their duration, physical exam findings  Preliminary procedures already completed (e.g., x-rays, CTs, lab work, ultrasound reports, scoped procedures, referrals to specialist, specialist evaluation)  Reason the study is being requested (e.g., further evaluation, rule out a disorder) Refer to the Prior Authorization Checklists on RadMD for more specific information.

Clinical Specialty Team Review Cardiac Orthopedic Oncology Neurology Abdomen/Pelvis (includes OB-US) General Studies Radiation Oncology Clinical Specialization Pods Overseen by a Physician Advisor Physician Panel of Board-Certified Physician Specialists with ability to meet any State licensure requirements Specialty Physician panels for peer reviews on specialty products (cardiac, OB ultrasound, radiation oncology, interventional pain management, surgery, sleep management) Physician Review Team Automated Timeliness Routing 10

Document Review NIA may request member’s medical records/additional clinical information. When requested, validation of clinical criteria within the member’s medical records is required before an approval can be made. Ensures that clinical criteria that support the requested test are clearly documented in medical records. Helps ensure that members receive the most appropriate, effective care. 11

NIA to Ordering Physician: Request for Additional Clinical Information A fax is sent to the provider detailing what clinical information is needed, along with a Fax Coversheet. We stress the need to provide the clinical information as quickly as possible so we can make a determination. Determination timeframe begins after receipt of requested clinical information. Failure to receive requested clinical information may result in non certification. 12

 Records may be submitted: Upload to www.RadMD.com Fax using the NIA coversheet Location of Fax Coversheets: Can be printed from www.RadMD.com Call Medicaid, Essential, Exchange, CHP, and Qualified Health Plans: 1-800-424-4952 Medicare and Dual Advantage : 1-800-424-5390 Use the case specific fax coversheets when faxing clinical information to NIA 13 Submitting Additional Clinical Information

• Additional clinical information submitted and reviewed – Procedure Approved • Additional clinical not complete or inconclusive – Escalate to Physician Review Designated & Specialized Clinical Team interacts with Provider Community. Clinical Review Process 14 1 2 3 4 Physicians’ Office Contacts NIA for Prior Authorization RadMD Telephone System Evaluates Request Based on Information Entered by Physician Key NIA Differentiators NIA Initial Clinical Specialty Team Review • Clinical information complete – Procedure Approved • Additional clinical information required – Pends for clinical validation of medical records NIA Specialty Physician Reviewers • NIA Physician approves case without peer to peer Peer-to-peer outbound attempt made if case is not approvable • NIA Physician approves case with peer to peer • Ordering Physician withdraws case during peer to peer • NIA Physician denies case based on medical criteria 92% of cases receive final determinations within 24 – 48 hours Generally, the turnaround time for completion of these requests is within two to three business days upon receipt of sufficient clinical information.

NIA Urgent/Expedited Authorization Process If an urgent clinical situation exists (outside of a hospital emergency room) during business hours, please call NIA immediately. The NIA website www.RadMD.com cannot be used for medically urgent or expedited prior authorization requests during business hours. Those requests must be processed by calling the NIA call center at 1-800-424-4952 (Medicaid, Essential, Exchange, CHP, and Qualified Health) or 1-800-424-5390 (Medicare and Dual Advantage). Outside of business hours, requests should be submitted through RadMD. Urgent/Expedited Authorization Process 15

Notification of Determination 16 Denial Notification  Validity Period - Authorizations are valid for:  60 days from the request date or based on clinical indications  Notifications will include an explanation of what services have been denied and the clinical rationale for the denial  A peer-to-peer discussion can be initiated once the adverse determination has been made.  A re-review is available with new or additional information.
 Timeframe for re-review is 60 calendar days for Medicaid members, 1 year for Medicare and Dual Advantage members, and 180 calendar days for Essential, Exchange, Qualified Health, and CHP members from the denial notification.  In the event of a denial, providers may appeal the decision by contacting Fidelis Care or following the appeal instructions provided in their determination letter or Remittance Advice (RA) notification. Approval Notification Denial Notification

Claims and Appeals NOTE: Consistent with CMS guidelines, multiple procedure discounts are applied when appropriate. (Please Confirm) 17 Claims Appeals Process How Claims Should be Submitted Rendering providers/Imaging providers should continue to send their claims directly to Fidelis Care. Providers are strongly encouraged to use electronic claims submission. Check on claims status by logging on to the Fidelis Care website at: https://providers.fideliscare.org/ Login In the event of a prior authorization or claims payment denial, providers may appeal the decision through Fidelis Care. Providers should follow the instructions on their denial letter or Remittance Advice (RA) notification.

Radiation Safety and Awareness Studies suggest a significant increase in cancer in dose estimates in excess of 50 mSv U.S. population is exposed to nearly five times more radiation from medical devices in 2019 than in 1980 CT scans and nuclear studies are the largest contributors to increased medical radiation exposure NIA has developed a Radiation Awareness Program designed to create member and physician awareness of radiation concerns 18

Provider Tools 19  Interactive Voice Response (IVR) System for authorization tracking RadMD Website www.RadMD.com  Request Authorization  View Authorization Status  View and manage Authorization Requests with other users  Upload Additional Clinical Information  View Requests for additional Information and Determination Letters  View Evidence based Clinical Guidelines (by diagnosis)  View Frequently Asked Questions (FAQs)  Cancer site checklists  View Other Educational Documents Toll Free Number Medicaid, Essential Plan, Exchange, CHP, and Qualified Health Plans: 1-800-424-4952 Medicare and Dual Advantage: 1-800-424-5390 Available Monday - Friday 8 AM – 8 PM EST Available 24/7 (except during maintenance)

NIA’s Website www.RadMD.com 20 Online Tools Accessed through www.RadMD.com: RadMD Functionality varies by user:  Ordering Provider’s Office – View and submit requests for authorization.  Rendering Provider – Views approved authorizations for their facility.  NIA’s Clinical Guidelines  Frequently Asked Questions  Quick Reference Guides  Checklist  RadMD Quick Start Guide  Utilization Matrices

Registering on RadMD.com To Initiate Authorizations STEPS: 1. Click the “New User” button on the right side of the home page. 2. Select “Physician’s office that orders procedures” 3. Fill out the application and click the “Submit” button. − You must include your email address in order for our Webmaster to respond to you with your NIA-approved username and password. NOTE: On subsequent visits to the site, click the “Sign In” button to proceed. 1 Everyone in your organization is required to have their own separate username and password due to HIPAA regulations. 2 3 Offices that will be both ordering and rendering should request ordering provider access, this will allow your office to request authorizations on RadMD and see the status of those authorization requests. 21

RadMD Enhancements: Shared Access Magellan Healthcare offers a Shared Access feature on our www.RadMD.com website.
Shared Access allows ordering providers to view authorization requests initiated by other RadMD users within their practice. If practice staff is unavailable for a period of time, access can be shared with other users in the practice. They will be able to view and manage the authorization requests initiated on www.RadMD.com, allowing them to communicate with patients and facilitate treatment.

Allows Users the ability to view all approved
authorizations for facility STEPS: 1. Click the “New User” button on the right side of the home page. 2. Select “Facility/office where procedures are performed” 3. Fill out the application and click the “Submit” button. − You must include your email address in order for our Webmaster to respond to you with your NIA-approved username and password. NOTE: On subsequent visits to the site, click the “Sign In” button to proceed. IMPORTANT • Everyone in your organization is required to have their own separate username and password due to HIPAA regulations. • Designate an “Administrator” for the facility who
manages the access for the entire facility. 1 2 3 If you have multiple staff members entering authorizations and you want each person to be able to see all approved authorizations, they will need to register for a rendering username and password. The administrator will have the ability to approve rendering access for each employee. This will allow users to see all approved authorizations under your organization. 23

Initiating or checking the status of an authorization  Website, www.RadMD.com  Toll-free number Medicaid, Essential Plan, Exchange, CHP, and Qualified Health Plans: 1-800-424-4952 Medicare and Dual Advantage: 1-800-424-5390  RadMDSupport@magellanhealth.com  Call 1-800-327-0641 24  Seth Cohen PT, DPT Provider Relations Manager 1-800-450-7281 Ext. 32418 cohens@magellanhealth.com When to Contact NIA Technical Issues/ Provider Service Line Provider Education requests or questions specific to NIA Providers: Initiating a Peer to Peer  Toll-free number Medicaid, Essential Plan, Exchange, CHP, and Qualified Health Plans: 1-800-424-4952 Medicare and Dual Advantage: 1-800-424-5390

RadMD Demonstration 25

Confidentiality Statement 26 The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to Fidelis Care members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Fidelis Care and Magellan Health, Inc.

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