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MA PAP302

Advanced Imaging Prior Authorizations


Provider Administrative Policy

Section
Prior Authorizations
Policy Date
May 2008
Status/Date
Revised/October 2011

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Advanced Imaging Prior Authorizations

All MRI/MRA, CT, PET and nuclear cardiology scans require prior authorization, unless performed during an emergency department visit or an inpatient or observation stay.

Blue Cross of Idaho also requires prior authorization for advanced imaging performed in a skilled nursing facility (SNF).

American Imaging Management (AIM), a radiology medical management organization, manages prior authorization requests for diagnostic imaging services.
See 
MA PAP102  for AIM contact information
Prior to scheduling an appointment for a non-emergent MRI/MRA, CT, PET or nuclear cardiology scan, ordering physicians are required to obtain authorization for these services. Authorizations can be done through the Blue Cross of Idaho provider portal at
bcidaho.com or by calling AIM. Failure to obtain prior authorization could cause a claim’s denial or delay.

Please note:

  • If the rendering/billing provider is contracting with Blue Cross of Idaho, prior authorization is required. For mobile providers that are contracting with Blue Cross of Idaho and render services in a contiguous county, prior authorization is required.
  • If the ordering provider is non-contracting with Blue Cross of Idaho and the rendering provider is contracting, prior authorization is required.
  • If the ordering and the rendering providers are not contracting with Blue Cross of Idaho, prior authorization is not required, but services may be subject to medical necessity review.

To ensure that you get authorization numbers, please consider the following:

  • Communicate to all personnel involved in outpatient scheduling to let them know that MRI/MRA, CT, PET and nuclear cardiology scans require prior authorization.
  • If the ordering physician`s office calls to schedule a patient for a procedure that requires prior authorization, request the authorization number.
  • If the ordering physician`s office has not obtained prior authorization, inform them of the requirement and advise them to complete authorization online or by contacting AIM at the toll free number found in MA PAP102.
  • If a patient calls to schedule an appointment for a procedure that has not been authorized, direct him/her back to the ordering physician.
  • If the ordering physician writes a prescription for the patient, he/she should write the authorization number on the prescription.
  • Include the authorization number on claims:
    – Field 23 of the a CMS 1500 form
    – Field 63 of the a UB-04 form

Online Authorizations

  1. Log on to the secure provider portal
  2. Select Advanced Imaging
  3. Automatic Login to Advanced Imaging will occur.

Have the following information ready prior to calling the AIM utilization management staff:

  • Name and office phone number of ordering physician
  • Member name, date of birth and identification number
  • Requested examination (CPT code is not required, but is helpful if available)
  • Name of provider`s office or facility and location where the service will be performed. If this is unknown at the time of service or the location is changed, it is helpful to notify AIM when the service is scheduled.
  • Anticipated date of service (if known)
  • Details justifying examination
  • Symptoms and their duration
  • Physical exam findings
  • Conservation treatment patient has already completed (i.e., physical therapy, chiropractic or osteopathic manipulation, hot pads, massage, ice packs, medication)
  • Preliminary procedures already completed (i.e., X-rays, CT’s, lab work, ultrasound, scoped procedures, referrals to specialists, specialist evaluation)
  • Reason the service is required (i.e., further evaluation, rule out a disorder)

Please have the following documents ready to fax, if requested:

  • Clinical notes
  • X-ray report
  • Previous CT/MRI report
  • Specialist reports/evaluations
  • Ultrasound reports

For specific guidelines about these procedures, please refer to the AIM Web site located within the provider portal at bcidaho.com and select Clinical Guidelines located at the bottom of the login screen.

You can appeal a denied prior authorization request for an advanced imaging study using the following process:

First Level
Upon receipt of a denial letter, the ordering physician or an office staff member can discuss any additional medical information with an AIM physician reviewer by calling 866-972-9842.

Second Level
Follow the member appeals process outlined in MA PAP405.

FAQs
For additional information and a list of frequently asked questions, please refer to the secure provider portal of the Blue Cross of Idaho Web site at
bcidaho.com.

CPT Code Matrix
Use the link below to access a matrix of CPT codes requiring prior authorization for provider use when working with American Image Management (AIM). This matrix contains all the CPT codes AIM manages on behalf of Blue Cross of Idaho but does not include codes for contrast agents, radio pharmaceuticals and supplies as well as codes submitted by facilities using CMS outpatient PPS coding (HCPCS C codes).

CPT Code Matrix

Nuclear cardiology services, which include myocardial perfusion imaging, infarct imaging and cardiac blood pool imaging, now require prior authorization. In addition, selective CPT add-on codes will require authorization through approval of the primary procedure in the group default code.  

 


Policy History

Date Action Reason
October 2011 Revised Language Revision
July 2010 Revised Matrix revised
March 2009 Revised New AIM language and process added
November 2008 Revised AIM language/matrix
August 2008 Revised Flexi Blue language removed
May 2008 Revised New matrix added

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