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New Century Health – Oncology Pathway Solutions
New Century Health (NCH) is an oncology quality management company. NCH will manage oncology prior authorization for all Ambetter members ages 18 and over. Beginning October 1, 2020, all oncology-related chemotherapeutic drugs and supportive agents will require clinical review by NCH before being administered in a physician’s office, outpatient hospital or ambulatory setting. This prior authorization requirement applies to both pharmacy dispensed and office administered medication requests.
New Century Health program benefits include:
- The use of clinical criteria, based on nationally-recognized guidelines, to promote evidence-based cancer care.
- Increased collaboration with physician offices to foster a team approach.
- Peer-to-peer discussions with medical oncologists who can understand and better discuss treatment plans.
- A provider web portal to:
- Obtain real-time approvals when selecting evidence-based NCH treatment care pathways.
- Determine which clinical documentation is necessary for medical necessity review.
- View all submitted requests for authorization in one location.
- Check member eligibility.
- The requesting physician must complete an authorization request using one of the following methods:
- Logging into the NCH Provider Web Portal
- Calling 1-888-999-7713, Option 1, Monday-Friday (7 a.m. - 7 p.m. CT)
Frequently Asked Questions:
Ambetter from Sunflower Health Plan Oncology Pathway Solutions
Q: Who is New Century Health?
A: New Century Health (NCH) is a comprehensive oncology quality management (OQM) company. Its platform optimizes the application of evidence-based medicine in the delivery of adult ambulatory cancer care.
Q: What is the Ambetter from Sunflower Health Plan Oncology Pathway Solutions program?
A: Ambetter from Sunflower Health Plan Oncology Pathway Solutions program includes prior authorization management for all infusible, injectable and oral chemotherapy agents, supportive drugs and symptom management drugs. This program emphasizes and supports the selection of preferred pathways for patient care and is administered by New Century Health.
Q: Is this for all Ambetter from Sunflower Health Plan members?
A: The Ambetter from Sunflower Health Plan Oncology Pathway Solutions program is for Ambetter from Sunflower Health Plan members 18 years old and older. Pediatric members (<18 years of age) are excluded from this program. The new prior authorization process applies to services for these members. Precertification, preauthorization and notification requirements all refer to the same process of preauthorization.
Q: When will the Oncology Pathway Solutions program begin?
A: The program will begin October 1, 2020, for Ambetter from Sunflower Health Plan members 18 years of age and older.
Q: How can a physician’s office request training for this program?
A: To request training, contact NCH Network Operations at 1-888-999-7713, Option 6.
Q: What are some key features of the program?
A: Key Features are:
- The online provider portal is available 24/7 offering:
- Real-time authorizations for treatment care pathways
- Reduced documentation requirements
- View of real-time status of authorization requests
- Eligibility verification
- Supportive telephonic authorization staff available by dialing 1-888-999-7713, Option 1, Monday–Friday (7 a.m. - 7 p.m. CT)
- Quick turnaround time on authorization requests submitted via fax or phone
- Physician discussion requests by medical oncologists
- NCH is a National Comprehensive Cancer Network (NCCN) licensee of the Drugs and Biologics Compendia. It uses nationally recognized, evidence-based treatment guidelines
- An NCH provider representative is available for support as needed
Q: What is the transition of care process?
A: Authorizations issued by Ambetter from Sunflower Health Plan before October 1, 2020 are effective until the authorization end date. Upon expiration, authorization requests must be submitted to NCH. If continued authorization is not obtained from NCH, affected claims may be denied. For services/treatments that did not require an authorization prior to October 1, 2020, an authorization will be required from New Century Health for service/treatment dates on and after October 1, 2020.
Q: Who should obtain prior authorization?
A: The physician organization ordering chemotherapeutic drugs or supporting agents for the treatment of cancer or related hematologic diseases must request preauthorization through NCH.
Q: How do I obtain prior authorization?
A: Submit chemotherapy requests to New Century Health via the following:
- PREFERRED: Log into NCH’s provider web portal at https://my.newcenturyhealth.com
- Contact NCH’s Utilization Management Intake Department at 1-888-999-7713 (Monday through Friday, 7 a.m. – 7 p.m. CT)
Q: Which drugs require preauthorization?
A: Ambetter from Sunflower Health Plan Oncology Pathway Solutions Program and administered by NCH, includes prior authorization management for all chemotherapeutic drugs, symptom management drugs and supporting agents for members with a diagnosis code included in the following range: C00-D49, E34.0, K31.7, K63.5, L53.8, Q85, D50-D53, D55-D62, D63.0, D63.8, D64, D68.5, D68.6, D69-D77, D89.2, I88, R11 (when cancer related) and Z41.8.
Q: Which specialties are included in the Ambetter from Sunflower Health Plan Oncology Pathway Solutions program?
A: Medical specialties providing cancer care and its supportive services, including Medical Oncology, Hematology, Urology, Surgical Oncology, Neurological Oncology and Gynecologic Oncology will submit their chemotherapy pre-authorizations through NCH.
Q: Who will be reviewing chemotherapy requests at New Century Health?
A: If the request does not meet evidence-based treatment guidelines, NCH may request additional information or initiate a consultation request with the ordering provider. NCH Medical Reviewers are licensed medical oncologists that use nationally recognized clinical *guidelines when performing reviews and are not incentivized to issue denials.
*Guidelines are available by contacting NCH’s Utilization Management at 1-888-999-7713, Option 1.
Q: What will the NCH authorization look like and how long is it valid?
A: The authorization identifier will start with “AR” followed by at least four digits (i.e. AR1000). Chemotherapeutic drugs and supporting agents will be authorized up to 90 days. Please bill with the Ambetter from Sunflower Health Plan prior authorization number provided by the health plan. The Ambetter from Sunflower Health Plan authorization number will begin with “OP” followed by 10 digits.
Q: What place of service does this prior authorization review process include?
A: The Oncology Pathway Solutions program applies to services rendered (e.g. chemotherapy administration) in an outpatient setting which could include the physician’s office, infusion centers or outpatient hospital locations.
Q: Are there services and/or other drugs that require authorization from Ambetter from Sunflower Health Plan Precertification Department?
A: Yes. Keep in mind that drugs for non-cancer/non-hematology diagnoses, that are listed on the Medicaid PDL require authorization from Ambetter from Sunflower Health Plan or Envolve Pharmacy Solutions.
Q: Where do I obtain a prior authorization for pharmacy dispensed chemotherapeutic and supportive agents?
A: Requests that were previously submitted to Pharmacy Solutions Provider should be submitted directly to NCH.
Q: Where do I submit related claims once prior authorization is obtained through NCH?
A: Submit claims to Ambetter from Sunflower Health Plan either electronically or by mail to the following address:
P.O. Box 5010
Farmington, MO 63640-5010
The payer ID for electronic claim filing is 68069. Please refer to the back of the member’s ID card for specific instructions.
Q: Does a prior authorization guarantee payment?
A: No, a prior authorization does not guarantee payment for services. Payment of claims is dependent on eligibility, covered benefits, provider contracts and correct coding and billing practices. For specific details, please refer to your Provider Manual.
Q: What will happen if the physician does not request and obtain an authorization?
A: If authorization is not obtained for the applicable drugs, Ambetter from Sunflower Health Plan may deny payment for respective drugs. Members cannot be held responsible for denied charges/services.