MHS FAQ NIA IMP

Date: 04/01/23

National Imaging Associates, Inc. (NIA) Interventional Pain Management (IPM) Frequently Asked Questions (FAQ’s) For Managed Health Services (MHS) Providers
Question	Answer
GENERAL
Why is MHS implementing an Interventional Pain Management (IPM) Program?	MHS is implementing this program to improve quality and manage the utilization of non-emergent, IPM procedures for MHS members. MHS providers will utilize the same tools through RadMD to request IPM procedures as they do today for advanced imaging procedures.
What IPM procedures does this include?	IPM Procedures that are included in this program: Spinal Epidural Injections Paravertebral Facet Joint Injections or Blocks Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis) Sacroiliac Joint Injections Sympathetic Nerve Blocks
Why did MHS select NIA?	NIA was selected to partner with us because of its clinically driven program designed to effectively manage quality and member safety, while ensuring appropriate utilization of resources for MHS membership.
Which MHS members will be covered under this relationship and what networks will be used?	NIA will manage non-emergent outpatient IPM procedures for MHS Medicaid and Medicare members effective June 1, 2023, through MHS’s contractual relationships.
PROGRAM START
What is the implementation date for this IPM Program?	The effective date of the program is June 1, 2023. MHS and NIA will be collaborating on provider related activities prior to the start date including provider training materials and provider education.
PRIOR AUTHORIZATION
What IPM services will require a provider to obtain a prior authorization?	The following outpatient IPM procedures require prior authorization through NIA: Spinal Epidural Injections Paravertebral Facet Joint Injections or Blocks Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis) Sacroiliac Joint Injections Sympathetic Nerve Blocks
When is prior authorization required?	Prior authorization is required for outpatient, non-emergent IPM procedures. Ordering providers must obtain prior authorization for these procedures prior to the service being performed. Note: Only outpatient procedures are within the program scope. All IPM procedures performed in the Emergency Room or as part of inpatient or intraoperative care do not require prior authorization through NIA.
Is prior authorization required for members currently undergoing treatment?	Yes, authorization is required for dates of service on or beyond June 1, 2023, even if the member is continuing treatment.
Who do we expect to order IPM procedures?	IPM procedures requiring medical necessity review are usually ordered by one of the following specialties. Anesthesiologists Neurologists Pain Specialist Orthopedic Spine Surgeon Neurosurgeon Other physicians with appropriate pain procedure training and certification
Are inpatient IPM procedures included in this program?	No, Inpatient IPM procedures are not included in this program.
Are intraoperative IPM procedures included in this program?	No, IPM procedures performed for pain management during a larger surgical procedure are not included in this program.
How does the ordering provider obtain a prior authorization from NIA for an outpatient IPM procedure?	Providers will be able to request prior authorization via the NIA website www.RadMD.com (preferred method) to obtain prior authorization for IPM procedures. RadMD is available 24 hours a day, 7 days a week. For Providers that are unable to submit authorizations using RadMD, our call center is available at 1-866-904-5096 for prior authorization, Monday-Friday, 8:00 a.m. to 8:00 p.m. EST.
What information will NIA require to receive prior authorization?	To expedite the process, please have the following information available before logging on to the website or calling the NIA call center staff (denotes required information): Name and office phone number of ordering physician Member name and ID number* Requested procedure* Name of provider office or facility where the service will be performed* Anticipated date of service* Details justifying the pain procedure: Date of onset of pain or exacerbation Physician exam findings and member symptoms (including findings applicable to the requested services) Clinical Diagnosis Date of prior IPM procedures. Diagnostic imaging results, where available.* Conservative treatment modalities completed, duration, and results (e.g., physical therapy, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication) Please be prepared to fax the following information, if requested: Clinical notes outlining onset of pain, conservative care modalities, outcomes and physical exam findings Date and results of prior IPM procedures Effectiveness of prior procedures on reducing pain Diagnostic Imaging results Specialist reports/evaluation
How do I send clinical information to NIA if it is required?	The most efficient way to send required clinical information is to upload your documents to RadMD (preferred method). The upload feature allows clinical information to be uploaded directly after completing an authorization request. Utilizing the upload feature expedites your request since it is automatically attached and forwarded to our clinicians for review. If uploading is not an option for your practice, you may fax utilizing the NIA specific fax coversheet. To ensure prompt receipt of your information: Use the NIA fax coversheet as the first page of your clinical fax submission. Please do not use your own fax coversheet, since it will not contain the case specific information needed to process the case Make sure the tracking number on the fax coversheet matches the tracking number for your request Send each case separate with its own fax coversheet IPM Providers may print the fax coversheet from www.RadMD.com. NIA will fax this coversheet to the IPM Provider during authorization intake or at any time during the review process. Using an incorrect fax coversheet may delay a response to an authorization request.
Can a provider request more than one procedure at a time for a member (i.e., a series of epidural injections)?	No. NIA requires prior authorization for each IPM procedure requested and will only authorize one procedure at a time.
What kind of response time can order providers expect for prior authorization?	The best way to maximize the turnaround time of an authorization request is to initiate the request through www.RadMD.com. Generally, within 2 to 3 business days after receipt of request with full clinical documentation, a determination will be made. In certain cases, the review process can take longer if additional clinical information is required to make a determination.
What will the NIA authorization number look like?	The NIA authorization number consists of alpha-numeric characters. In some cases, the ordering provider may instead receive an NIA tracking number (not the same as an authorization number) if the provider’s authorization request is not approved at the time of initial contact. Providers will be able to use either number to track the status of their request online or through an Interactive Voice Response (IVR) telephone system.
If requesting an authorization through RadMD and the request pends, what happens next?	You will receive a tracking number and will need to submit clinical documentation that supports the requested IPM procedure.
Can RadMD be used to submit an expedited authorization request?	RadMD can only be used to initiate expedited authorization requests after normal business hours. Requests that are submitted during normal business hours must be called into NIA’s call center through the toll-free number, 1-866-904-5096 for processing.
How long is the prior authorization number valid?	The authorization number is valid for 30 days from the date of request.
Is prior authorization necessary for IPM procedures if MHS is NOT the member’s primary insurance?	Yes. Authorization is required if MHS is secondary to another plan.
If a provider obtains a prior authorization number does that guarantee payment?	An authorization number is not a guarantee of payment. Authorizations are based on medical necessity and are contingent upon eligibility and benefits. Benefits may be subject to limitations and/or qualifications and will be determined when the claim is received for processing.
Does NIA allow retro-authorizations?	Yes. Retrospective review of completed procedures are evaluated for medical necessity and to determine whether there was an urgent or emergent situation that prohibited the provider from obtaining prior authorization for the service and to determine whether medical necessity guidelines were met. It is important that key physicians and office staff be educated on the prior authorization requirements. Claims for IPM procedures, as outlined above, that have not been properly authorized will not be reimbursed. Physicians administering these procedures should not schedule or perform procedures without prior authorization. .
What happens if I have a service scheduled for June 1, 2023?	An authorization can be obtained for all IPM procedures for dates of service June 1, 2023, and beyond, beginning June 1, 2023. NIA and MHS will be working with the provider community on an ongoing basis to continue to educate providers that authorizations are required.
Can a provider verify an authorization number online?	Yes. Providers can check the status of member authorization quickly and easily by going to the website at www.RadMD.com.
Will the NIA authorization number be displayed on the MHS website?	No, the authorization will not be displayed on the MHS website
What if I disagree with NIA’s determination?	In the event of a prior authorization or claims payment denial, providers may appeal the decision through MHS. Providers should follow the instructions on their non-authorization letter or Explanation of Payment (EOP) notification.
SCHEDULING PROCEDURES
Will NIA make a final determination based on the Anticipated Date of Service?	NIA does not guarantee final determination of the request by the anticipated date of service. The anticipated date of service (provided during request for authorization) is used to determine timing between procedures Please be advised that NIA needs 2 to 3 business days after the receipt of clinical information to review and render a decision on a request. Please do not schedule or perform the procedure until you have an approved authorization.
Do ordering physicians have to obtain an authorization before they call to schedule an appointment?	NIA will require the name of the facility/provider where the IPM procedure is going to be performed and the anticipated date of service. Ordering providers should obtain prior authorization before scheduling the procedure.
WHICH MEDICAL PROVIDERS ARE AFFECTED?
Which medical providers are affected by the IPM Program?	Specialized Providers who perform IPM procedures in an outpatient setting. MHS providers will need to request a prior authorization from NIA to bill the service. Providers who perform IPM procedures are generally located at: Ambulatory Surgical Centers Hospital outpatient facilities Provider offices
CLAIMS RELATED
Where do providers send their claims for outpatient, non-emergent pain management services?	MHS network providers should continue to send claims directly to MHS. Providers are encouraged to use EDI claims submission
How can providers check claims and claims appeal status?	Providers should continue to check claims and appeals status with MHS.
MISCELLANEOUS
How is medical necessity defined?	NIA defines medical necessity as services that: Meets generally accepted standards of medical practice; be appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient evidence and professionally recognized standards; Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome; Be appropriate to the intensity of service and level of setting; Provide unique, essential, and appropriate information when used for diagnostic purposes; Be the lowest cost alternative that effectively addresses and treats the medical problem; and rendered for the treatment or diagnosis of an injury or illness; and Not furnished primarily for the convenience of the member, the attending physician, or other provider.
Will provider trainings be offered closer to the implementation date?	Yes, NIA will conduct provider training sessions before the implementation of this program.
Where can a provider find NIA’s Guidelines for Clinical Use of Pain Management Procedures?	NIA’s IPM Guidelines can be found on the website at www.RadMD.com. They are presented in a PDF file format that can easily be printed for future reference. NIA’s clinical guidelines have been developed from practice experiences, literature reviews, specialty criteria sets and empirical data.
Does the MHS member ID card change with the implementation of this IPM Program?	No. The MHS member ID card does not contain any Magellan Healthcare information on it and the member ID card will not change with the implementation of this IPM Program.
RE-REVIEW, RE-OPEN, AND APPEALS PROCESS
Is the re-review or re-open process available for the IPM program once a denial is received?	Once a denial determination has been made, if the office has new or additional information to provide, a re-review can be initiated by uploading via RadMD or faxing (using the case specific fax cover sheet) additional clinical information to support the request. A re-review for MHS Medicaid members must be initiated within 10 calendar days from the date of denial and prior to submitting a formal appeal. Re-opens are not allowed for MHS Medicare members. NIA has a specialized clinical team focused on IPM. Peer-to-peer discussions are offered for any request that does not meet medical necessity guidelines. The IPM provider may call 1-866-904-5096 to initiate the peer-to peer-process. These discussions provide an opportunity to discuss the case and collaborate on the appropriate services for the member based on the clinical information provided.
Who should a provider contact if they want to appeal a prior authorization decision?	Providers are asked to please follow the appeal instructions given on their non-authorization letter or Explanation of Benefits (EOB) notification.
RADMD ACCESS
If I currently have RadMD access, will I need to apply for additional access to initiate authorizations for IPM procedures?	If the user already has access to RadMD, RadMD will allow you to submit an authorization for any procedures managed by NIA.
What option should I select to receive access to initiate authorizations?	Selecting “Physician’s office that orders procedures” will allow you access to initiate authorizations for pain management procedures.
How do I apply for RadMD access to initiate authorization requests if I don’t have access?	User would go to our website www.radmd.com. Click on NEW USER. Choose “Physician’s office that orders procedures” from the drop-down box Complete application with necessary information. Click on Submit Once an application is submitted, the user will receive an email from our RadMD support team within a few hours after completing the application with an approved username and a temporary passcode. Please contact the RadMD Support Team at 1-800-327-0641 if you do not receive a response within 72 hours.
What is rendering provider access?	Rendering provider access allows users the ability to view all approved authorizations for their office or facility. If an office is interested in signing up for rendering access, you will need to designate an administrator. User would go to our website www.RadMD.com Select “Facility/Office where procedures are performed” Complete application Click on Submit Examples of a rendering facility that only need to view approved authorizations: Hospital facility Billing department Offsite location Another user in location who is not interested in initiating authorizations
Which link on RadMD will I select to initiate an authorization request for IPM procedures?	Clicking the “Request Pain Management or Minimally Invasive Procedure” link will allow the user to submit a request for an IPM procedure.
How can providers check the status of an authorization request?	Providers can check on the status of an authorization by using the “View Request Status” link on RadMD’s main menu.
How can I confirm what clinical information has been uploaded or faxed to NIA?	Clinical Information that has been received via upload or fax can be viewed by selecting the member on the View Request Status link from the main menu. On the bottom of the “Request Verification Detail” page, select the appropriate link for the upload or fax.
Where can providers find their case-specific communication from NIA?	Links to case-specific communication to include requests for additional information and determination letters can be found via the View Request Status link.
If I did not submit the initial authorization request, how can I view the status of a case or upload clinical documentation?	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.
Paperless Notification: How can I receive notifications electronically instead of paper?	NIA defaults communications including final authorization determinations to paperless/electronic. Correspondence for each case is sent to the email of the person submitting the initial authorization request. Users will be sent an email when determinations are made. No PHI will be contained in the email. The email will contain a link that requires the user to log into RadMD to view PHI. Providers who prefer paper communication will be given the option to opt out and receive communications via fax.
CONTACT INFORMATION
Who can I contact if we need RadMD support?	For assistance, please contact RadMDSupport@MagellanHealth.com or call 1-800-327-0641. RadMD is available 24/7, except when maintenance is performed every third Thursday of the month from 9 pm – midnight PST.
Who can a provider contact at NIA for more information?	Providers can contact April Sabino, Provider Relations Manager, at 1-800-450-7281, ext. 31078 or 1-410-953-1078 or ajsabino@magellanhealth.com

Last Updated: 04/27/2023