Provider Refresher Training
Provider Training Program Agenda
Welcome and Opening Remarks
Program Components
Facility Selection Support Program
How the Program Works:
• Authorization Process
• Algorithms Guidelines
• Radiation Awareness
• Provider Self-Service Tools (RadMD and IVR)
• NIA Provider Relations and Contact Information
• Questions and Answers
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Program Components
• Utilization Management/Authorizations: NIA's proprietary, evidence-based
decision algorithms support scripting for call center representatives or online, leading
to quick procedure approval or consultation with our radiology experts.
• Information and Transaction Tools: Our online resource,,
gives ordering providers the ability to request and obtain authorizations, reference
lists of nearby imaging facilities, locate authorizations and submit 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 the Health Plan 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, etc.)
• Provider Privileging: The program includes privileging of the Health Plan’s
freestanding facilities and the Health Plan’s in-office providers for advanced and
cardiac imaging. The program promotes continuous quality improvement, provides
scope of practice limitations and enables consumers to make educated health care
decisions. Hospitals are excluded from the privileging program.
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Facility Selection Support
Facility Selection Support Goals
The facility selection process is based on patient support and cost
• Primary consideration is always the clinical aspect of the patient
when making facility recommendations.
• Helps ensure that patients go to quality imaging facilities that are
conveniently located.
• Supports the education of both the provider and patient about
cost-effective facility alternatives.
• Facilitates the delivery of tests at free-standing, outpatient facilities
(when appropriate) to support lower costs
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How Facilities are Selected
During prior authorization, the
authorization representative will help
the ordering provider select a facility
based on:
• Facilities meeting NIA’s quality
requirements and patient’s
clinical need
• Location and cost differential
• Convenience items important to
• Prior Authorization for a high cost
facility will be confirmed with the
consumer if there is no clinical
All facilities meeting NIA’s approved facility
requirements for the indicated test. Facilities
also meet the patient’s clinical requirements
Facilities located in or close to
required zip code. Preference
given to lower cost facilities
Facilities with
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Convenience 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
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The Authorization
NIA Prior Authorization is required for:
Non-emergent outpatient, short stay and urgent care
PET Scan
Diagnostic Nuclear Medicine
Nuclear Cardiology/MPI
Stress Echo
• Any code specifically cited in the Health Plan/NIA Billable CPT® Code
Claims Resolution Matrix.
• All other procedures will be adjudicated and paid by the Health Plan per
their guidelines.
• Authorizations are valid for sixty (60) days from date of initial request.
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NIA Prior Authorization is not required for:
• Inpatient, Observation or Emergency Room:
PET Scan
Diagnostic Nuclear Medicine
Nuclear Cardiology/MPI
Stress Echo
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NIA Clinical UM Authorization Process
Physicians’ office
contacts NIA for prior
authorization of study
System evaluates request
based on physician
entered information
Clinical information
complete – procedure
Clinical information
not complete –
additional information
Initial Clinical Specialty
Team Review
Physician Review
Additional clinical
information complete
Additional clinical
not complete or
Request for
specific clinical
Physician Approves
Case Without Peer-toPeer
Physician Approves
Case With Peer-to-Peer
Ordering Physician
Withdraws Case
Physician Denies
92% of all cases receive final determinations in 24 – 48 hours.
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NIA Clinical Expertise and Provider
 NIA reviews more than 450,000 advanced
imaging provider requests each month.
 Algorithms and guidelines are reviewed
and mutually approved by Geisinger Health Plan
and NIA chief medical officers.
 Many NIA algorithms recommend substituting
more costly but more effective imaging technology.
Our goal–the most appropriate test early in an
episode of care for “Client” members.
 Clinical consultation is a hallmark of NIA–
we have 86 board-certified physicians representing
radiology and a host of other specialties available
for physician-to-physician (peer-to-peer) discussion.
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Access Clinical Guidelines on RadMD
Home Page
This screen allows you to select:
•Health Plan
•Type of Study
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Clinical Guidelines Search
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From a drop down list on the NIA Clinical
Guideline page, Select the appropriate
Health Plan and Study
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Select the exam you want to review. A PDF
document will open the guideline selected.
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Lumbar Spine CT
Example of Clinical Information Needed
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Algorithms can recommend Substituting
More Costly but More
Effective Imaging Technology
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Prior Authorization Checklist
Information needed to make Medical Necessity Determination
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Requests Pended for Clinical Review
Upload Clinical Documentation or use
Fax Coversheet
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Radiation Awareness
Radiation Awareness Program
NIA, in partnership with the Health Plan, has implemented a
Radiation Awareness Program to educate the provider community
as well as the members on radiation exposure.
Goals of the Program
• Inform ordering providers of past exposure
• Offer provider education and consultation
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Radiation Awareness Program
Distinguishing Features
• Claims-based, member-specific radiation accumulator
• NIA will advise ordering providers of patients with high level exposure
(=>50 mSv cumulatively while with the Health Plan) to radiation during
authorization requests and offer peer-to-peer consultation.
• Provider/member educational content is available
• Medical necessity decisions are not impacted by the patient’s radiation
exposure - information is intended to assist the provider with the member’s
More information on radiation awareness is available on our website,
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Radiation Awareness
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Radiation Exposure Adds Up Over Time
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Self Service Tools
and Usage
Self Service Tools and Usage
• Interactive Voice Response (IVR)
• Use tracking number to check status of cases
• Web site:
• Use tracking number to review an exam request
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NIA Web Site
The NIA web site gives providers access to:
• Information concerning approved
authorizations. Go to
and login with username and password.
• Search the site using the patient’s ID
number, name or authorization number.
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Initiate an Authorization Request on RadMD
Available Sunday-Friday, 5:00 a.m. to 12:00 am
Saturday 8:00 a.m. to 1:00 p.m. EST
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Imaging Facilities
View all Requests Entered by Ordering
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Search Authorization by Name, Member ID
Number or view All Requests
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NIA RadMD Website
User-friendly, near-real-time Internet tool offered by NIA
o Sign in at
RadMD website offers access to:
o Member preauthorization's
o Date initiated
o Exam requested
o Valid billing codes (CPT)
Helpful resources including:
o Evidence-based Clinical Guidelines (by diagnosis)
o Outpatient Radiology Billable CPT® Codes Claim Resolution Matrix
o Radiology Utilization Management Quick Reference Guide
o NIA Frequently Asked Questions (FAQs)
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To get started, visit
• Login and 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 username and password.
• HIPAA regulations require everyone in your organization to have his or her
own username and password.
• On subsequent visits to the site, click the login button to proceed.
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RadMD Demonstration
NIA Provider
NIA Contact Information
• NIA Provider Relations Manager
• Charmaine Gaymon
• Phone: (410) 953-2615
• Email: [email protected]
• Provides educational tools to ordering and rendering providers on imaging
processes and procedures.
• Liaison between Geisinger Health Plan Provider Relations and NIA.
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Questions and

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