Ambetter of Oklahoma (Ambetter) and Wellcare of Oklahoma (Wellcare) Musculoskeletal Care Management (MSK) Program Quick Reference Guide for Ordering Physicians/Surgeons

Date: 05/30/23

Effective August 1, 2023

Ambetter and Wellcare has entered into an agreement with National Imaging Associates, Inc. (NIA), to implement a Musculoskeletal Care Management (MSK) Program.  This program includes prior authorization for non-emergent MSK procedures:  outpatient interventional spine pain management services; and inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries.  This decision is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

The following procedures are included in the MSK Program for Ambetter and Wellcare members: Providers may begin contacting NIA on August 1, 2023 to obtain prior authorization for procedures below scheduled on or after August 1, 2023.

• Outpatient interventional spine pain management services
• Inpatient and outpatient hip surgeries
• Inpatient and outpatient knee surgeries
• Inpatient and outpatient shoulder surgeries
• Inpatient and outpatient lumbar and cervical spine surgeries

Prior Authorization Implementation

As a provider of MSK services that require prior authorization, it is essential that you develop a process to ensure that the appropriate authorization number(s) has been obtained.

It is the responsibility of the ordering physician/surgeon and rendering facility to ensure that prior authorization was obtained, when necessary.  Payment will be denied for procedures performed without a prior authorization, including the MSK surgery hospital admission, and the member cannot be balance-billed for such procedures.

Procedures Requiring Prior Authorization:*

Outpatient Interventional Spine Pain Management Services:

• Spinal Epidural Injections
• Paravertebral Facet Joint Injections or Blocks
• Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)
• Sacroiliac Joint Injections
• Sympathetic Nerve Blocks
• Spinal Cord Stimulators

Outpatient and Inpatient Hip Surgery Services:

• Revision/Conversion Hip Arthroplasty
• Total Hip Arthroplasty/Resurfacing
• Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincher & labral repair)
• Hip Surgery – Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy)

Outpatient and Inpatient Knee Surgery Services:**

• Revision Knee Arthroplasty
• Total Knee Arthroplasty (TKA)
• Partial-Unicompartmental Knee Arthroplasty (UKA)
• Knee Manipulation under Anesthesia (MUA)
• Knee Ligament Reconstruction/Repair
• Knee Meniscectomy/Meniscal Repair/Meniscal Transplant
• Knee Surgery – Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)

Outpatient and Inpatient Shoulder Surgery Services:**

• Revision Shoulder Arthroplasty
• Total/Reverse Arthroplasty or Resurfacing
• Partial Shoulder Arthroplasty/Hemiarthroplasty
• Shoulder Rotator Cuff Repair
• Shoulder Labral Repair
• Frozen Shoulder Repair/Adhesive Capsulitis
• Shoulder Surgery – Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

Outpatient and Inpatient Spine Surgery Services:

• Lumbar Microdiscectomy
• Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)
• Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single & Multiple Levels
• Cervical Anterior Decompression with Fusion – Single & Multiple Levels
• Cervical Posterior Decompression with Fusion – Single & Multiple Levels
• Cervical Posterior Decompression (without fusion)
• Cervical Artificial Disc Replacement – Single & Two Levels
• Cervical Anterior Decompression (without fusion)
• Sacroiliac Joint Fusion 

NIA will manage non-emergent outpatient interventional spine pain management services, and inpatient and outpatient hip, knee, shoulder, and spine surgeries through the existing contractual relationships with Ambetter and Wellcare.  If an urgent/emergent clinical situation exists outside of a hospital emergency room, please contact NIA immediately with the appropriate clinical information for an expedited review.  The number to call to obtain a prior authorization for Ambetter is 1-800-509-1842, and for Wellcare is 1-800-424-5388 for providers in Oklahoma.

Please refer to NIA’s website to obtain the Ambetter and Wellcare NIA Billable CPT^® Codes Claim Resolution/Utilization Review Matrix for all of the CPT-4 codes that NIA authorizes on behalf of Ambetter and Wellcare.

Prior Authorization Information

To ensure that authorization numbers have been obtained, please adhere to the following guidelines.

Interventional Pain:

• Interventional pain management procedures performed in the emergency room or on an inpatient basis do not require prior authorization through NIA.
• All outpatient interventional pain management services require a prior authorization through NIA for each procedure performed.
• It is the responsibility of the ordering physician to obtain authorization for all interventional pain management procedures outlined. Failure to do so may result in non-payment of your claim.
• Authorizations are valid for 60 days from the date of request.

 

Outpatient and Inpatient Musculoskeletal Surgeries:

• Emergency musculoskeletal surgery (admitted via the Emergency Room) does not require prior authorization through NIA.
• Non-emergent outpatient and inpatient hip, knee, shoulder, and spine surgery services require prior authorization through NIA.
• The ordering physician must obtain prior authorization with NIA prior to performing the surgery.  Facility admissions do not require a separate prior authorization. However, the facility should ensure that an NIA prior authorization has been obtained prior to scheduling the surgery/procedure.
• NIA’s medical necessity review and determination is for the authorization of the surgeon’s professional services and type of surgery being performed.  NIA will provide the Ambetter and Wellcare with the surgery type requested and authorization determination.
• Authorizations are valid for 2 days from the date of request for inpatient surgery, 60 day from the date of request for outpatient surgery.

 

Checking Authorizations

You can check on the status of members’ authorizations quickly and easily by going to the NIA website.  After obtaining a secure password sign-in to select, the My Exam Requests tab to view all outstanding authorizations.

 

Submitting Claims

Claims continue to go directly to Ambetter and Wellcare.

For Ambetter:

Please send your claims for MSK procedures to the following address:

            Ambetter of Oklahoma

            Attn: Claims Department P. O. Box 5010

            Farmington, MO 63640-5010

           

Providers are encouraged to use EDI claims submission. Ambetter’s payor ID number is 68069.

 

For Wellcare:

Please send your claims for MSK procedures to the following address:

            Wellcare Health Plans

            Attn: Claims Department P. O. Box 5010

            Farmington, MO 63640-5010

                       

Providers are encouraged to use EDI claims submission. Wellcare’s payor ID number is 68069.

 

Frequently Asked Questions

In this section NIA addresses commonly asked questions received from providers.

 

Where can I find NIA’s Guidelines for these MSK procedures?

Guidelines can be found on NIA’s website.

 

Is prior authorization necessary if Ambetter or Wellcare is not the member’s primary insurance?

No.

 

What does the NIA authorization number look like?

The NIA authorization number consists of alpha/numeric characters (e.g., 1234X567). In some cases, the ordering physician may instead receive an NIA tracking number (not the same as an authorization number) if the physician’s authorization request is not approved at the time of initial contact. Physicians can use either number to track the status of their request on the RadMD website or via our Interactive Voice Response telephone system.

 

Who can I contact at NIA for questions, complaints, and appeals, etc.?

Please use the following NIA contacts by type of issue:

• To educate your staff on NIA procedures and to assist you with any provider issues or concerns, contact your NIA Area Provider Relations Manager.
• Preauthorization and claims payment complaints/appeals: Follow the instructions on your non-authorization letter or Explanation of Benefit (EOB)/Explanation of Payment (EOP) notification.

 

How do referring/ordering physicians know who NIA is?

Ambetter and Wellcare sends orientation materials to referring/ordering providers. Ambetter and Wellcare and NIA also coordinate outreach and orientation activities.

 

What does the member ID card look like?  Does it have both NIA and Ambetter and Wellcare information on the card?  Or is there two cards?

The Ambetter and Wellcare member ID cards do not have NIA identifying inform