Prior Authorization Provider Orientation for Oscar

1 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information. Prior Authorization Provider Orientation for OscarProvider Orientation 2019 eviCore healthcare. All Rights presentation contains CONFIDENTIAL and PROPRIETARY information. Comprehensive Solutions9 The industry s most comprehensive clinical evidence-based guidelines4k+employees including 1k cliniciansEngaging with 570k+providersAdvanced, innovative, and intelligent technology100M Members Managed Nationwide2 Headquartered in Bluffton, SCOffices across the US including: Melbourne, FL Plainville, CT Sacramento, CA Lexington, MA Colorado Springs, CO Franklin, TN Greenwich, CT eviCore healthcare. All Rights presentation contains CONFIDENTIAL and PROPRIETARY information. RadiologyCardiologyMusculoskeletalSleep ManagementMedical OncologySpecialty DrugRadiation TherapyLab ManagementPost-Acute CareEnd-to-End SolutionIntegrated platform 9 Comprehensive Solutions eviCore healthcare.

2 All Rights presentation contains CONFIDENTIAL and PROPRIETARY information. 34 Our Clinical Approach 260 board-certified medical directors Diverse representation of medical specialties 800 nurses with diverse specialties and experience Dedicated nursing and physician teams by specialty for Radiology, Cardiology, Oncology, OB-GYN, Spine/Orthopedics, Neurology, and Medical/Surgical5 Clinical PlatformFamily MedicineInternal MedicinePediatricsSports MedicineOB/GYNC ardiologyNuclear MedicineAnesthesiologyRadiation OncologySleep MedicineOncology/HematologySurgery General Orthopedic Thoracic Cardiac Neurological Otolaryngology SpineRadiology Nuclear Medicine Musculoskeletal NeuroradiologyMulti-Specialty ExpertiseThe foundation of our solutions:6 Evidence-Based GuidelinesAligned with National SocietiesDedicated pediatric guidelinesContributions from a panel of community physicians Experts associated with academic institutionsCurrent clinical literature American College of Therapeutic Radiology and Oncology American Society for Radiation Oncology American Society of Clinical Oncology American Academy of Pediatrics American Society of Colon and Rectal 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

3 Of Rheumatology American Academy of Sleep Medicine American Urological Association National Comprehensive Cancer Network7 Service ModelThe Client Provider Operations team is responsible for high-level service delivery to our health plan clients as well as ordering and rendering providers nationwide 8 Client Provider OperationsBest ColorsClient Provider Representatives are cross-trained to investigate escalated Provider and healthplan issues. Client ProviderRepresentativesClient Service Managers lead resolution of complex service issues and coordinate with partners for continuous ServiceManagersRegional Provider Engagement Managers are on-the-ground resources who serveas the voice of eviCore to the Provider community. Regional Provider Engagement Managers9 Why Our Service Delivery Model WorksOne centralized intake point allows for timely identification, tracking, trending, and reporting of all issues.

4 It also enables eviCore to quickly identify and respond to systemic issues impacting multiple 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 issues are handled by a teamof representativeswho are cross trained to respond to a variety of issues. There is no reliance on a single individual to respond to your Compatibility 10 The 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 website Login or Register Point web browser to Click on the Providers linkCreating An Account12To create a new account, click An Account13 Select CareCoreNational and complete the user registration will be able to access the MedSolutionsportal as An Account14 Review information provided, and click Submit Registration.

5 User Registration-Continued15 Accept the Terms and Conditions, and click Submit. User Registration-Continued16 You will receive a message on the screen confirming your registration is successful. You will be sent an email to create your a Password17 Uppercase lettersLowercase lettersNumbersCharacters ( , ! ? *)Your password must be at least (8) characters long and contain the following:Account Log-In18To log-in to your account, enter your User ID and Password. Agree to the HIPAA Disclosure, and click Login. Welcome Screen19 Providers will need to be added to your account Prior to case submission. Click the Manage Account tab to add Provider information. Note: You can access the MedSolutionsPortal at any time without having to provide additional log-in information. Click the MedSolutionsPortal button on the top right corner to seamlessly toggle back and forth between the two Practitioners20 Click the Add Provider Practitioners21 Enter the Provider s NPI, State, and ZIP Code to search for the Provider record to add to your account.

6 You are able to add multiple providers to your Practitioners22 Select the matching record based upon your search criteriaManage Your Account23 Once you have selected a practitioner, your registration will be completed. You can then access the Manage Your Account tab to make any necessary updates or changes. You can also click Add Another Practitioner to add another Provider to your Portal Overview Legacy CareCoreNational PortaleviCore will begin accepting requests on12/15/19 for dates of service 1/1/19and beyond25 Authorization UpdatePrior Authorization applies to services that are: Outpatient Elective / Non-emergent DiagnosticPrior Authorization does not apply to services that are performed in: Emergency room 23-hour observation InpatientIt is the responsibility of the ordering Provider to request Prior Authorization approval for services.

7 ** Inpatient requests will continue to be handled by Oscar in the current manner. Applicable Membership 26 Authorization is currently requiredfor Oscar Insurance members enrolled in New York, New Jersey, Texas, Ohio and Tennessee. Newly expanded to Arizona and Florida as of 1/1 There may be a circumstance where you have utilized the web portal to request a Provider Authorization and received the message member not found . If this occurs, please contact eviCore by phone at 1-855-252-1118. You will be connected with an agent who will ask for the information required for the Prior Authorization request. The agent will execute on building a manual case for that member. The completed case will be sent to the eligibility team for verification of Not Found28 Prior AuthorizationRequired: Programs: Radiology Cardiology Lab Management Radiation Therapy Musculoskeletal(Chiropractic and Pain Management) Sleep Medical Oncology Joint and Spine Surgery Specialty DrugTo verify all procedure codes requiring Prior Authorization please refer to the Oscar Provider portal: How to request Prior Authorization :29 Prior Authorization RequestsOr by phone.

8 1-855-252-1118 7 to 7 (EST)Monday 24/7 and the quickest way to create Prior authorizations and check existing case status30 Clinical Review ProcessEasy for providers and staffSTARTM ethods of IntakeNurseReviewPredictive Intelligence/Clinical Decision SupportAppropriate DecisionMDReviewClinical consultationReal-Time Decision with Web and Phone31 Needed InformationMemberMember IDMember nameDate of birth (DOB)FacilityFacility nameNational Provider identifier (NPI)Street addressReferring PhysicianPhysician nameNational Provider identifier (NPI)Tax identification number (TIN)Fax numberiRequestsCPT code(s) for requested procedureThe appropriate diagnosis code for the working of differential diagnosisIf clinical information is needed, please be able to supply: Imaging studies and Prior test results related to the diagnosis Office notes related to the current diagnosis Therapy notes related to the current diagnosis32 Prior Authorization Outcomes All requests are processed within 2business days after receipt of all clinical Requests:Delivery: Communication of denial determination.

9 Communication of the rationale for the denial. How to request a Clinical Consultation. Faxedto the ordering Provider and rendering facility. Mailedto the :Denied Requests:Delivery: Faxedto ordering Provider and rendering facility. Mailedto the member. Information can be printed on demand by logging. into eviCore healthcare CircumstancesOutpatient Urgent Studies:Outpatient Urgent Studies:Appeals: eviCore healthcare will be delegated for first level member and Provider appeals. Requests for appeals must be submitted in writing to eviCore within 180 days of the initial determination. A written notice of the appeal decision will bemailed to the member and faxedto the Provider . Medically urgent requests are defined as conditions that are a risk to the patient s life, health, ability to regain maximum function, or the patient is having severe pain that required a medically urgent procedure.

10 Contact eviCore by phone or use our online portal to request an expedited Prior Authorization review and provide clinical information. Urgent Cases will be reviewed within 72 hours of the request. Verbaloutreach is made to the ordering *New* Certification Summary CareCoreNational Portal now includes a Certification Summary tab, to better track your recently submitted cases. The work list can also be filtered -as seen above. Initiating A Case35 Choose request a clinical certification/procedure to begin a new case Program36 Select the Programfor your Provider37 Select the Practitioner/Group for whom you want to build a Health Plan38 Choose the appropriate Health Plan for the case request. If the health plan does not populate, please contact the plan at the number found on the member s identification the plan is chosen, please select the Provider address in the next drop down box.