To facilitate the approval process, be sure you have the following information ready before logging on to RadMD.com or calling the NIA Magellan Utilization Management staff:
- Name, office phone number and fax number of referring provider
- Member name and ID number
- Requested therapy discipline (PT and/or OT)
- Name of treating provider office or facility where the service will be performed, phone number and fax number
- Date of the initial evaluation
- Treating diagnosis, body region being treated and onset date
- Surgery date and procedure performed (if applicable)
- Brief medical history and any summary of previous therapy
- Baseline evaluation—including current and prior functional status
- Objective tests and measures appropriate to the discipline of therapy
- Standardize test with raw score, standardized scores and interpretation
- School programs, including frequency and goals (for habilitative services)
- Documentation for home and community programs the patient is involved in (for habilitative services)
- Treatment prognosis and rehab potential
- Treatment plan including interventions planned
- Specific functional goals that are measurable, sustainable and time-specific
- Projected frequency and duration of treatment
- Discharge plan
Subsequent therapy requests
- Re-evaluations and treatment plans since the last authorization
- Therapy treatment documentation since last authorization
- Summary of patient status and updated discharge plan
- DeanCare Gold members are exempt from the registration/authorization process through NIA Magellan.
- Dean Health Plan members with an Autism Diagnosis are also exempt.
- Not all Dean Health Plan ASO groups have the same authorization requirements.
- ASO groups that allow for eight auto-approved visits need to follow the Care Registration process and register the member with NIA Magellan at the initial visit.
- To verify an ASO groups eligibility, contact the Customer Care line indicated on the back of the member’s ID card.
Note: Clinical information must be documented in the therapy treatment record and/or other medical record documentation, such as diagnostic imaging or testing reports, physician referral documentation. Handwritten notes on cover sheets, telephone calls or other fax pages not reflected in therapy treatment record or other objective documents will be noted—“handwritten note on cover sheet (telephone call, etc.) without confirmation in treatment record”—but will not constitute actionable information for clinical decision making. Be prepared to upload or fax medical records supporting the required information on the checklist.
Medical necessity determinations are based on NIA Magellan Guidelines (available on RadMD.com) and Apollo Managed Care clinical guidelines—comprehensive, evidenced-based healthcare review criterion (available upon request).