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SHPBN-2018-011 UPDATE: NIA Post Therapy Services

Date: 05/07/18

Sunflower Health Plan is partnering with National Imaging Associates, Inc. (NIA) to ensure that the physical medicine services (physical, occupational, and speech therapy) provided to our Sunflower Health Plan members are consistent with nationally recognized clinical guidelines.

Effective April 1, 2018, physical, occupational, and speech therapy services will NOT require prior authorization, unless:

  • The therapies are being provided under the Traumatic Brain Injury (TBI) waiver benefit, and/or
  • The therapies are being provided in the member’s home.

Authorizations for members currently receiving OT/PT/Speech therapies under the TBI waiver will be extended at the current amount through June 30, 2018, to allow time for this transition. Requests for therapies provided under the TBI waiver for new members, or for existing members for services after June 30 should be sent to the member’s assigned care manager.

Beginning April 1, 2018, physical, occupational and speech therapy services claims will be reviewed by NIA peer consultants to determine whether the services met/meet Sunflower Health Plan’s policy criteria for medically necessary and medically appropriate care. These determinations are based on a review of the objective, contemporaneous, clearly documented clinical records. These reviews help us determine whether such services (past, present, and future) are medically necessary and otherwise eligible for coverage.

If the service will be provided in the member’s home, it is the responsibility of the provider to obtain an approved prior authorization from the Utilization Management department at Sunflower Health Plan. You may submit your request via the portal, through fax at 888-453-4316, or you may contact the Prior Authorization department at 877-644-4623.

If the prior authorization request is denied and you wish to assist the member in filing an appeal, effective April 1, 2018, those may be sent to Sunflower Health Plan via fax at 888-453-4755, by phone at 877-644-4623, or by mailing to Sunflower Health Plan Appeals Department at 8523 Lenexa Drive, Suite 200, Lenexa, KS 66214.

Claims should continue to be submitted to Sunflower Health Plan for adjudication. All therapy claims must contain the appropriate modifier when submitted to the health plan in order to ensure appropriate adjudication. Failure to follow Kansas Medicaid guidelines regarding specialty modifiers (GN, GO, GP) may result in the inability to process your claim. Medical necessity denials can be appealed through NIA. All other claims appeals are processed through the health plan.

NIA may request clinical documentation to support the medical necessity and appropriateness of the care. There is no need to send patient records at this time. NIA will notify you if records are needed. If records are necessary, it is important you know that Sunflower Health Plan cannot adjudicate your claims until the necessary information is received. If the documentation received fails to establish that care is/was medically necessary Sunflower Health Plan may deny payment for services and future related therapy services thereafter. If requested records are not received, claims will be denied due to lack of information.

You will be able to upload requested records on the NIA website or through the NIA fax number at 1-800-784-6864. Medical necessity reviews are based on clinical guidelines which are available on the NIA website at: http://www1.radmd.com/solutions/physical-medicine.aspx.

As the nation’s leading specialty health care management company, NIA delivers comprehensive and innovative solutions to improve quality outcomes and optimize cost of care. If NIA therapy peer reviewers determine that the care provided fails to meet our criteria for covered therapy services, you and the member will receive notice of coverage decision.

Please keep in mind you will need to ensure that the member has not exhausted his/her PT/OT/ST benefit and/or has a habilitative benefit prior to providing services. The purpose of NIA is to review medical necessity of PT/OT/ST services, and not to manage the member’s benefits. Please verify member eligibility by utilizing the Sunflower Health Plan Secure Provider Portal or calling our customer service at 1-877-644-4623.

We appreciate your participation and look forward to your assistance in assuring that Sunflower Health Plan members receive physical, occupational and speech therapy services in a quality, clinically appropriate manner.

Should you have questions, please contact Sunflower Health Plan Provider Services at 1-877-644-4623.