Point32 Hip/Knee/Shoulder Surgeries (HKSS) Prior Authorization (PM) Form

Harvard Pilgrim’s Hip/Knee/Shoulder Surgeries (HKSS) prior authorization program

Harvard Pilgrim’s Hip/Knee/Shoulder Surgeries (HKSS) prior authorization program is managed through an arrangement with National Imaging Associates (NIA).

Non-emergent Hip, Knee and Shoulder services listed below are managed through the HKSS Management and Prior Authorization program:

Hip

• Femoroacetabular impingement (FAI) hip surgery (includes CAM/pincer & labral repair)
• Hip surgery – other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra- articular arthroscopy knee)
• Revision/conversion hip arthroplasty
• Total hip arthroplasty/resurfacing

Knee

• Revision Knee Arthroplasty
• Total knee arthroplasty (TKA)
• Partial-unicompartmental knee arthroplasty (UKA)
• Knee manipulation under anesthesia (MUA)
• Knee ligament reconstruction/repair
• Knee meniscectomy/meniscal repair/meniscal transplant
• Knee surgery – other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)

Shoulder

• Revision Shoulder Arthroplasty
• Total/reverse shoulder arthroplasty or resurfacing
• Partial shoulder arthroplasty/hemiarthroplasty
• Shoulder rotator cuff repair
• Shoulder labral repair
• Frozen shoulder repair/adhesive capsulitis
• Shoulder surgery – other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

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 manages Harvard Pilgrim’s outpatient advanced imaging program, select spine services and sleep studies.

NIA has developed clinical guidelines that outline the key surgical treatments and clinical indications for common hip, knee and shoulder disorders. These guidelines are based on practice experiences, literature reviews, specialty criteria sets, expert opinions from leading orthopedic and sports medicine 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 any of the non-emergent inpatient and outpatient HKSS procedures contained in this policy. Prior authorization from NIA can be requested in the following ways:

1. on-line at www.radmd.com, or
2. by telephone at 800-642-7543 (NIA’s Call Center hours of operation are Mon.–Fri., 8 a.m.–8 p.m. EST).

Harvard Pilgrim Health Care—StrideSM Medicare Advantage Provider Manual15(continued) August 2020

STRIDEsm (HMO) MEDICARE ADVANTAGE Hip/Knee/Shoulder Surgery and Prior Authorization (cont.)

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
• Date of onset and duration of symptoms
• Physical exam findings
• Results of prior diagnostic imaging
• History of previous medical and surgical treatment
• Name and address of provider office or facility where requested service will be performed
• Valid, specific 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

ElectronicServicing 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 in the HPHConnect section of the provider website.)

• 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.