Radiology Benefit
Management Program
Provider Training
June 2009
Provider Training Program Agenda
Welcome and Opening Remarks
CareSource’s Implementation of a Radiology Benefit Management
(RBM) Program
About NIA
The Provider Partnership
The Provider Assessment Program
How the Program Works:
 The Authorization Process
The Authorization Appeals Process
 The Claims Process
 The Claims Appeals Process
Provider Self-Service Tools (RadMD and IVR)
RadMD Demo
Provider Communication and Service as High Priority
 NIA Provider Relations and Contact Information
 Questions and Answers
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Why a Radiology Benefit Management
Program for CareSource?
CareSource elected to implement a Radiology Benefit Management Program, in partnership
with NIA, to ensure:
Through ongoing utilization and quality monitoring, CareSource identified
trends that indicated the need for further analysis of the radiology
procedures being provided to CareSource members.
Clinical literature demonstrates that many high-tech radiology exams are
performed when there is not a clinical indication that the test will alter
diagnostic certainty. Therefore, patients are needlessly exposed to
radiation and health care costs are wastefully consumed.
To appropriately manage the increasing utilization of these services so as
to avoid:
The use of resources without benefit to the patients that the system is intended
to help.
Unsustainable cost trends, image quality issues, and safety concerns.
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Clinical Data Review
Patient Safety
 Each CT study (3 or more scans) will provide about 50 millisieverts
(msv) of exposure depending on various factors.
 Large-scale studies of radiation related workers demonstrate
significant increased risk of cancer for those exposed to more than
150 msv; with children being at greater risk than adults.
 The current estimate for incidence of cancer due directly to CT
radiation exposure is 1.5 - 2% of all cancers in the U.S.
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Clinical Data Review (continued)
The American College of Radiology published an article, later referenced in
a story in the Cleveland Plain Dealer. The data represented 115% increase
in CT scans performed in the U.S. between 1998 and 2005 and a 383%
spike in office CT scans performed by non-radiologists. Ohio data showed
a 117% increase overall and 3,954% increase in office CT scans performed
by non-radiologists.
 For a 2-year period between May 2005 and April 2007, Caresource
experienced a 20% year-over-year trend for CT scans alone.
Because of poor continuity of care, lack of medical home, drug seeking
behavior and other factors many CareSource members have had far in
excess of three (3) CT studies and increased radiation risk, suggesting
patient safety issues that need to be managed.
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About NIA
NIA is accredited by
National Imaging Associates (NIA) -- chosen as the solution for
National and Regional Health Plans covering more than 18
million lives due to:
Distinctive clinical focus.
Accredited by NCQA and URAC-certified.
Innovation and Stability -- Parent is Magellan Health Services -- enhances
operational competencies, IT capabilities and patient support tools; affords
financial stability for growth and continued investment in innovative
Operating in Ohio since 2001 – Solid Experience in Working with the Ohio
Health Care Community.
Focus / Results: Maximizing diagnostic services value; promoting
patient safety through:
A clinically-driven process that safeguards appropriate diagnostic
treatment for CareSource beneficiaries.
Convenient access to a network of qualified providers.
Identification of patient-specific convenience items to support unique
member needs.
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The NIA Provider Partnership Model
Process of Ensuring Quality Services
 NIA’s privileging programs ensure that high-quality facilities—meeting
rigorous credentialing criteria—deliver services to members.
Dedication to Provider Service and Convenience
Provider Call Center
Dedicated PR staff
Authorization Call Center
Interactive Voice Response (IVR)
Innovative Provider Tool – RadMD
Education and Training Programming
Ongoing Outreach to Providers – ordering provider surveys, individual
ordering / rendering practice retraining, satisfaction surveys, etc.
Provider Newsletters
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The Provider Assessment
Process for
Rendering Providers
NIA’s Provider Assessment Program
NIA has a Comprehensive Program for Evaluating Imaging
Providers Selected to Participate in the CareSource Radiology
Benefit Management Program
The NIA Provider Assessment Program encompasses:
 Both Credentialing and Privileging into the selection process.
 Reviews both free-standing facilities (FSF) and radiologists.
NIA’s Credentialing Program
 Focuses on NIA contracted providers – FSFs and radiologists.
 Applies a rigorous set of standards to ensure quality and
 NIA’s Network and Credentialing Committee makes decisions about
participation status.
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How the Program Works:
-- The Authorization Process
-- The Claims Process
-- Provider Appeals
Program Components
Utilization Management/Authorizations: NIA's proprietary, evidence-based
decision support algorithms support scripting for call center representatives or
online - leading to quick procedure approval or consultation with our radiology
Information and Transaction Tools: Web site provides the ability
for ordering providers to request and obtain authorizations, reference lists of
nearby imaging facilities, locate authorizations given, gain rapid authorization
requests. Providers report a high level of satisfaction with their use of RadMD
finding it a simple tool to use and a time-saver for staff.
Ordering Provider Program: Analyze referral patterns with CareSource and
develop additional education and outreach opportunities to the provider
community to review various facility options based upon convenience factors for
members (i.e., free parking, on a public transportation line, weekend hours,
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Facility Selection Goals
The facility selection process is based on quality of care, patient support and
cost effectiveness:
- Always considers the clinical aspect of the patient when making
facility recommendations
- Helps ensure that patients go to quality imaging facilities with
convenient services that meet their needs.
- Facilitates the delivery of tests at free-standing, outpatient facilities
(when appropriate) to support lower costs
The more the ordering physician knows about their patient’s unique needs,
the better the experience can be customized to the patient
With this additional support, the patient is more likely to have the ordered
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How Facilities are Selected
During prior authorization, the
authorization representative
will help the ordering provider select
a facility based on:
Clinical requirements (driven by type
of test, patient need)
 Patient zip code
Patient convenience services
 Cost effectiveness
Prior authorization will be tied to a
specific facility
All available facilities that meet approved facility
requirements for indicated test
Search narrowed to facilities that
perform requested test within zip code
Search narrowed to
facilities with identified
convenience services
within the selected
zip code
Facility Selected
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Convenient Services that can be Selected
Transportation and parking
- Public transportation accessibility
- Free parking
Language Assistance
- Languages spoken by office staff
- Telecommunication equipment for deaf patients
Weekend or Evening Hours
- Extended evening hours
- Weekend hours
- Onsite availability of someone to watch child
- Onsite child play area
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The Authorization
Prior Authorization is required for:
Non-Emergent Outpatient:
 CT
 PET Scan
No Prior Authorization is required for:
Inpatient CT, MRI/MRA/MRS, PET Scan
Hospital Observation CT, MRI/MRA/MRS, PET Scan
Emergency Room CT, MRI/MRA/MRS, PET Scan
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Clinical Validity of Algorithms
NIA currently reviews more than 450,000 advanced imaging requests
each month.
Algorithms and guidelines are reviewed and approved by CareSource
Medical Directors.
Many of our current algorithms recommend the substitution of more
costly but more effective imaging technology. Our goal is to suggest
the most appropriate test early in an episode of care.
Consultative communication is a hallmark of NIA – NIA has a team of
62 board-certified physicians representing radiology and a host of
other specialties available for physician to physician discussions.
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NIA’s Authorization Process
The ordering physician is responsible for obtaining prior authorization.
The rendering provider must ensure that prior authorization has been obtained
and it is recommended that you not schedule procedures without prior
Procedures performed without proper authorization will not be reimbursed.
If the radiologist or rendering provider feels that, in addition to the study already
authorized, an additional study is needed, either the radiologist or rendering
provider should proceed with the additional study and contact NIA within one (1)
business day to initiate the review process for medical necessity.
If an urgent clinical situation exists outside of a hospital emergency room, the
radiologist or rendering provider should proceed with the study and contact NIA
the next business day to go through the normal review process.
Separate pre-certification numbers are not needed for CT-guided biopsy,
CT-guided radiation therapy and some MR-guided procedures.
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NIA Prior Authorization Process
Agent Level
office contacts
NIA for prior
via web or
100% cases
Procedure is
approved by
~60% cases
Nurse Level
Call time of
approximately 5
Case is
transferred to
nurse for
~40% cases
Physician Level
Procedure is
approved by
~20% cases
Case is
transferred to
physician for
~20% cases
On average, 92% of all cases receive final determinations within 24-48 hours
Procedure is
approved by
a physician
~10% cases
Procedure is
denied by a
~5% cases
Case is
withdrawn by
the ordering
~5% cases
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Authorization Process and Components
(Annual Statistics)
173 Customer
Service Associates
62 Board certified
Physician Clinical
68 staff in support
56 Initial Clinical
Review staff (RN,
34 staff in support
Inbound calls
Case Reviews
Case Reviews
RadMD Authorizations
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The Authorization
Appeals Process
The Authorization Appeals Process
In the event of a denial and you are not satisfied with a medical
decision, you may appeal the decision through CareSource.
You will receive appeal information in the denial letter that will be sent
to you.
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The Claims Process
How Claims Should be Submitted
Rendering providers/Imaging providers should continue to send their
claims directly to CareSource at:
P.O. Box 8730
Dayton, OH 45401-8730
Providers are strongly encouraged to use EDI claims submission with
CareSource Payer Identification number: 31114.
Check on claims status by logging on to the CareSource website
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The Claims Appeals
The Claims Appeals Process
In the event of a claims payment denial, you may appeal the decision
through CareSource.
Send your claim appeal letter with supporting documentation to:
Attn: Appeals
P.O. Box 2008
Dayton, OH 45401-2008
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Self Service Tools
and Usage
Multi-Channel Provider Relations Strategy
Internet Offerings
Interactive Voice Response
Member Eligibility
Secure Messaging
Provider Data Change Form
Initiate Authorization (Ordering Provider)
Authorization Inquiry
IVR – Interactive Voice Response
• Member Eligibility
• Authorization Inquiry
Provider Service Line &
Provider Relations Staff
• Provider Support & Inquiries
• Provider Forums/Education
• Centralized and Regional Support
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RadMD Demo
Self Service Tools and Usage
Interactive Voice Response (IVR)
 Use tracking number to check status of cases.
 Use tracking number to review an exam request.
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NIA Website --
Information concerning approved
authorizations can be viewed at after login with
username and password.
Providers may search based on
the patient’s ID number, name or
authorization number.
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NIA Website – Ordering Providers
Provide you with instant access to much of the high tech imaging prior
authorization information that our call center staff provides, but in an
easily accessible Internet format.
We encourage all ordering providers to submit all requests on line.
With RadMD, the majority of cases will be authorized online with ease;
however, we will resolve pended cases through our Clinical Review
Website can provide you with up-to-the-hour information member
authorizations, including date initiated, date approved, exam category,
valid billing codes and much more.
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NIA Website - Imaging Facilities
User-friendly, near-real-time Internet tool offered by NIA.
 Available from 5:00 a.m. to 12:00 a.m. EST Monday – Friday;
Saturdays from 8:00 a.m. to 1:00 p.m. EST
 Log on to RadMD
 website can offer providers direct access to:
Members’ authorizations
 Date initiated
 Exam requested
 Valid billing codes (CPT)
 Secure messaging
 Ease of updating practice information under My Profile
 Current provider news
Access to a full range of helpful content including our Imaging Provider
Handbook, Diagnostic Imaging Guidelines, Quick Reference Guide
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To get started, visit
Click the “New User” button on the right side of the home page.
Fill out the application and click the “Submit” button.
You must include your e-mail address in order for our Webmaster to
respond to you with your NIA-approved user name and password.
Everyone in your organization is required to have his or her own
separate user name and password due to HIPAA regulations.
On subsequent visits to the site, click the “Login” button to proceed.
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NIA Provider RadMD User Survey Findings
Q: What are the most notable characteristics of this tool?
Common Themes:
“Enjoy using RadMD because it saves time and is user-friendly.”
 “To the point, no long detailed explanations” or “repeat questions”.
 “Provides immediate status of authorizations.”
“Don’t have to tie up phone lines.”
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NIA Provider
Provider Relations Structure and Portals
Dedicated provider service line for provider inquiries
 Radiology Network Services line at 1-800-327-0641
Dedicated NIA Provider Relations Manager for CareSource Providers -Stephanie Martin who will be there for you to:
Educate Ordering and Rendering Providers as to how the
program works
Serve as an Ombudsman for the Provider Community
coordinating with the CareSource Provider Relations Team.
Answer your questions and assist you with researching
an issue at:
• Phone: (410) 953-2631
• Via e-mail:
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Questions and

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