© 2019 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.
Cardiology Provider OrientationBlue Cross Blue Shield of Rhode Island
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Company Overview
2
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Comprehensive
Solutions9The industry’s most
comprehensive clinical
evidence-based guidelines
4.9k+ employees including
1k clinicians
Engaging with 570k+ providers
Advanced, innovative, and
intelligent technology
3
100M
Members
Managed
Headquartered in Bluffton, SC
Offices across the US including:
• Melbourne, FL
• Plainville, CT
• Sacramento, CA
• Lexington, MA
• Colorado Springs, CO
• Franklin, TN
• Greenwich, CT
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Cardiology
50M lives
Radiology
70M lives
Musculoskeletal
40M lives
Sleep
16M lives
Post-Acute Care
1.7M lives
Medical Oncology
30M lives
Radiation Therapy
39M lives
Lab Management
19M lives
Specialty Drug
723k lives
100 million lives
Integrated platform
4
9Comprehensive
Solutions
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This presentation contains CONFIDENTIAL and PROPRIETARY information.
Cardiology Solution - Our Experience
20+ Regional and National Clients
• 37.7M Commercial Memberships
• 2.3M Medicare Memberships
• 5.98M Medicaid Memberships
10k+
Cases built per day
50M members managed nationwide
5
13 YearsManaging Cardiology Services
Members Managed
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Our Clinical Approach
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Multi-Specialty Expertise
Clinical Staffing
Anesthesiology
Cardiology
Chiropractic
Emergency Medicine
Family Medicine
• Family Medicine / OMT
• Public Health & General Preventative Medicine
Internal Medicine
• Cardiovascular Disease
• Critical Care Medicine
• Endocrinology, Diabetes & Metabolism
• Geriatric Medicine
• Hematology
• Hospice & Palliative Medicine
• Medical Oncology
• Pulmonary Disease
• Rheumatology
• Sleep Medicine
• Sports Medicine
Dedicated nursing and physician specialty
teams for various solutions
Competency-Based Routing
• Allows clinically complex cases to automatically route to a specific queue, based on clinical
specialty for review
• Ensures greater accuracy of decision-making across the many clinical disciplines
800 Nurses with
diverse
specialties /
experience
>300 Medical
Directors
Covering
51different
specialties
Radiology
• Diagnostic Radiology
• Neuroradiology
• Radiation Oncology
• Vascular & Interventional
Radiology
Sleep Medicine
Sports Medicine
Surgery
• Cardiac
• General
• Neurological
• Spine
• Thoracic
• Vascular
Urology
Medical Genetics
Nuclear Medicine
OB / GYN
• Maternal-Fetal Medicine
Oncology / Hematology
Orthopedic Surgery
Otolaryngology
Pain Mgmt. / Interventional Pain
Pathology
• Clinical Pathology
Pediatric
• Pediatric Cardiology
• Pediatric Hematology-Oncology
Physical Medicine & Rehabilitation
Pain Medicine
Physical Therapy
Radiation Oncology
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This presentation contains CONFIDENTIAL and PROPRIETARY information.
The foundation of our solutions:
Evidence-Based Guidelines
Aligned with National Societies
Dedicated
pediatric
guidelines
Contributions
from a panel
of community
physicians
Experts
associated
with academic
institutions
Current
clinical
literature
• American Society for Radiation Oncology
• American Society of Clinical Oncology
• American Academy of Pediatrics
• American Society of Colon and Rectal Surgeons
• American Academy of Orthopedic Surgeons
• North American Spine Society
• American Association of Neurological Surgeons
• American College of Obstetricians and Gynecologists
• The Society of Maternal-Fetal Medicine
• American College of Cardiology
• American Heart Association
• American Society of Nuclear Cardiology
• Heart Rhythm Society
• American College of Radiology
• American Academy of Neurology
• American College of Chest Physicians
• American College of Rheumatology
• American Academy of Sleep Medicine
• American Urological Association
• National Comprehensive Cancer Network
8
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This presentation contains CONFIDENTIAL and PROPRIETARY information.
Our Service Model
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Enhancing outcomes through Client and Provider engagement
Enabling Better Outcomes
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Regional Provider
Engagement Managers
Regional Provider Engagement
Managers are on-the-ground
resources who serve as the
voice of eviCore to the provider
community.
Client Experience Manager
Client Service Managers lead
resolution of complex service issues
and coordinate with partners for
continuous improvement.
Client & Provider Operations
Client Provider Representatives
are cross-trained to investigate
escalated provider and health
plan issues.
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Why Our Service Delivery Model Works
One centralized intake point
allows for timely identification,
tracking, trending, and reporting
of all issues. It also enables
eviCore to quickly identify and
respond to systemic issues
impacting multiple providers.
Complex issues are escalated
to resources who are the
subject matter experts and can
quickly coordinate with matrix
partners to address issues at a
root-cause level.
Routine issues are handled by
a team of representatives who
are cross trained to respond to a
variety of issues. There is no
reliance on a single individual to
respond to your needs.
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Cardiology
Prior Authorization Process
eviCore healthcare will begin accepting requests by phone on
September 23, 2019 and on the web portal on October 1, 2019 for dates
of service October 1, 2019 and beyond
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Program Overview
Prior authorization applies
to services that are:
• Outpatient
• Elective / Non-emergent
• Diagnostic
Prior authorization
does not apply to services
that are performed in:
• Emergency room
• Inpatient
• 23-hour observation
It is the responsibility of the ordering provider to request prior
authorization approval for services.
Applicable Membership
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Authorization is required for BCBSRI members enrolled in the following
programs:
• Medicare Advance/ Medicare Advantage
• Commercial
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Prior Authorization Required:
• Myocardial Perfusion Imaging (Nuclear Stress)
• Echo / Echo Stress
• Diagnostic Heart Catheterization
• Cardiac Imaging (CT. MRI, PET)
To find a list of CPT (Current Procedural Terminology) codes that require prior authorization
through eviCore, please visit:
https://www.evicore.com/implementation/healthplan/blue-cross-blue-shield/rhode-island
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Prior Authorization Process
16
Trigger
event
Visit
provider
Clinical
Decision
Support
Nurse
review
MD
review
Appropriate
decision
Provider
requests prior
authorization
Peer-to-peer
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22
Needed Information
Member
Member ID
Member name
Date of birth (DOB)
Referring Physician
Physician name
National provider identifier (NPI)
Tax identification number (TIN)
Fax number
Rendering Facility
Facility name
National provider identifier (NPI)
Tax identification number (TIN)
Street address
Supporting Clinical
Patient’s clinical presentation.
Diagnosis Codes.
Disease-Specific Clinical Information.
Patient’s intended treatment plan
If clinical information is needed, please be able tosupply:
• Prior tests, lab work, and/or imaging studies performed related to this diagnosis
• The notes from the patient’s last visit related to the diagnosis
• Type and duration of treatment performed to date for thediagnosis
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Prior Authorization Outcomes
• Faxed to ordering provider and
rendering facility
• Mailed to the member
• Information can be printed on
demand from the eviCore
healthcare Web Portal
• Communication of denial
determination
• Communication of the
rationale for the denial
• How to request a Peer
Review
• Faxed to the ordering provider
and rendering facility
• Mailed to the member
Approved Requests• All determinations are turned
around for Commercial in 2
business days not to exceed 15
calendar days for non-urgent
requests. Medicare is 9 calendar
days for non- urgent requests. Both
are after receipt of all necessary
clinical information. Urgent requests
are determined within 72 hours.
• Authorizations are typically good for
90 calendar days from the date of
determination.
Delivery Method
Denied Requests Delivery Method
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Prior Authorization Outcomes – Medicare Advance/ Medicare
Advantage
• If your case requires further clinical discussion
for approval, we welcome requests for clinical
determination discussions from referring
physicians prior to a decision being rendered.
• In certain instances, additional information
provided during the pre-decision consultation is
sufficient to satisfy the medical necessity criteria
for approval
Pre-Decision Consultation
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Special Circumstances
Retrospective Studies• Retrospective requests for Commercial must be submitted within 365 calendar days from the date of
service . For Medicare, requests must be submitted within 27 months.
• Retrospective requests are reviewed for clinical urgency and medical necessity. Turn around time on retro
requests is 30 calendar days.
Outpatient Urgent Studies• Contact eviCore by phone 888-233-8158 or web through www.bcbsri.com to
request an expedited prior authorization review and provide clinical information
• Urgent Cases will be reviewed with 72 hours of the request.
• eviCore will process first level appeals for Commercial members only
• Requests for commercial appeals must be submitted to eviCore within 180 calendar days of the initial
determination
• Medicare appeals should be submitted to BCBSRI Grievance & Appeals unit
• The imaging request and all clinical information provided will be reviewed by a physician other than the one
who made the initial determination.
• A written notice of the appeal decision will be mailed to the member and faxed to the provider
Appeals
Appeals
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Special Circumstances- Medicare Advance/Medicare Advantage
Submit to BCBSRI Grievance and Appeals UnitBy Mail: 500 Exchange St, Providence, RI 02903By e-mail: [email protected] fax: 401-459-5668
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This presentation contains CONFIDENTIAL and PROPRIETARY information. 22
WEB
The eviCore online portal is the quickest, most efficient way to request prior authorization
and check authorization status and is available 24/7. By visiting www.bcbsri.com providers
can spend their time where it matters most — with their patients!
Or by phone:
Phone Number:888-233-8158
7:00 a.m. to 7:00 p.m.
Monday - Friday
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This presentation contains CONFIDENTIAL and PROPRIETARY information.
Web Portal Services
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Signing into eviCore’s portal
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Once logged into your bcbsri.com account on the provider portal, select
Preauthorization
Note: If you do not have access to the bcbsri.com provider portal, please register or contact Provider Relations for assistance.
Signing into eviCore’s portal
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Select the cardiology link to bring you to the eviCore site to begin the authorization
process.
Portal Compatibility
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The eviCore.com website is compatible with the following web browsers:
• Google Chrome
• Mozilla Firefox
• Internet Explorer 9, 10, and 11
You may need to disable pop-up blockers to access the site. For information on
how to disable pop-up blockers for any of these web browsers, please refer to our
Disabling Pop-Up Blockers guide.
Home Tab
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The Home Page will have two worklists: My Pending Worklist and Recently Submitted Cases
My Pending Worklist
• Save case information and complete case at a later time
• Submit additional clinical to a pending case after submission without having to fax
Recently Submitted Cases
• Cases that are pending review and/or cases recently approved or denied
Search/Start Case – Member Lookup
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To conduct a Patient Lookup, first select the
appropriate insurance company from the Insurer
drop down. Next, enter the Member ID or First
Name, Last Name and Date of Birth for the result to
be returned.
For Case/Auth Lookup, you will
only need to enter the Case ID
or Authorization Number at the
bottom of the page and tab over
to hit Search.
Search/Start Case – Member Lookup
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If a partial ID is put in the search box, a
list of members will populate. A patient
can be selected once the patient is
highlighted blue. Please make sure you
select the correct patient by verifying the
patient’s name and DOB before clicking
Create Case.
If there are cases associated with the
patient, they will populate once the
patient is selected. Double click on a
case ID in the Patient History to open
that case.
Case Creation – CPT/ICD Codes
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• Begin typing the CPT and ICD codes or descriptions, then click the appropriate option with
your cursor. Modifier selections will populate for the code, if applicable. The portal allows
selection of unlimited CPT and ICD codes.
• A box will populate allowing you to enter the retro date of service if retrospective requests
are able to be initiated via the web for the health plan specified.
Case Creation – Ordering Physician
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• Select from a default Physician or search by Name, Tax ID, or NPI number, and select
the state.
• Once the correct physician displays, select by clicking on the record. Then hit “Save &
Next.”
• There is the option to “Use Referring Physician as Requested Facility,” if appropriate.
Case Creation – Facility
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• Select from a default Facility or search by clicking the Search Facility button and entering the
Facility Name, Tax ID, or NPI number. For in-office procedures, click the Look-Up IOP button,
and choose from the list.
• Once the correct facility displays, select by clicking on the record. Then hit “Save & Next.”
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Review Details/Accept Terms
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Providing Clinical Information
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Providing Clinical Information
Providing Clinical Information
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• You can choose to “Submit for Additional Review” to proceed to the clinical upload and
review process, or you may “Voluntarily Cancel Request.”
• Cancelling the request ensures there will not be a denial in the patient’s history.
Providing Clinical Information
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Depending upon the health plan, specific options for
providing clinical will be available. You will then be asked
to attached the electronic clinical information available.
Providing Clinical Information
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You can attach clinical notes or
documents by clicking Browse
and selecting the correct file(s)
located on your computer.
Hit Apply to continue or Cancel to add
additional information at a later time.
You can type in free text notes as
clinical information. Hit save for
any notes entered in the text box.
Providing Clinical Information
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Once you click Apply you will receive a message that
your documentation has been accepted and that your
case has been sent for medical review.
Case Summary Page – Pending Case
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• Once you submit a case for medical review, you will be redirected to the Pending Case
Summary Page where you’ll be able to view case information including case number and
current status/activity.
Case Summary Page – Approved Case
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• The Approved Case Summary Page will provide case information such as the
authorization number and effective/end date of the authorization.
Case Summary Page – Denied Case
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• The Denied Case Summary Page will provide case information as well as the denial
rational. Case Summary reports can be accessed/printed at any time.
Provider Resources
43
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This presentation contains CONFIDENTIAL and PROPRIETARY information.
Client Provider
Operations
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Prior Authorization Call Center
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7:00 AM - 7:00 PM (Eastern Time): (888) 233-8158
• Obtain prior authorization or check the status of an existingcase
• Discuss questions regarding authorizations and casedecisions
• Change facility or CPT Code(s) on an existingcase
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Client Provider
Operations
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Web-Based Services
45
www.eviCore.com
To speak with a Web Specialist, call (800) 646-0418 (Option #2) or
email [email protected].
• Request authorizations and check case status online –24/7
• Pause/Start feature to complete initiatedcases
• Upload electronic PDF/word clinical documents
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Client Provider
Operations
Pre-Certification
Call Center
Web-Based
Services
Documents
Provider Resources: Client Provider Operations
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To reach eviCore Client Services, call (800) 575-4517 (Option #3) or
email [email protected]
• Eligibility issues (member, rendering facility, and/orordering
physician)
• Questions regarding accuracy assessment, accreditation,and/or
credentialing
• Issues experienced during case creation
• Request for an authorization to be resent to the healthplan
© eviCore healthcare. All Rights Reserved.
This presentation contains CONFIDENTIAL and PROPRIETARY information.
Client Provider
Operations
Web-Based
Services
Documents
Provider Resources: Implementation Website
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Blue Cross Blue Shield of Rhode Island Provider Resources Page -
includes all implementation documents:
https://www.evicore.com/implementation/healthplan/blue-cross-blue-
shield/rhode-island
• Provider Orientation Presentation
• CPT code list of the procedures that require prior authorization
• eviCore clinical guidelines
• FAQ and QRG
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For Eligibility and Benefits:
For benefits and eligibility questions, please contact the
Physician & Provider Service Center at 401-274-4848 or 1-800-
230-9050 for out-of-state callers or visit bcbsri.com on the
Provider Portal
.
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Thank You!