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MA PAP305

Advanced Imaging Pre/Post Service Process


Provider Administrative Policy

Section
Provider Prior Authorizations
Policy Date
March 2009
Status/Date
New/March 2009
Provider Type(s)
All Providers  

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 Pre/Post Service Process

Pre Service Reconsiderations
Advanced imaging studies performed in a non-emergent outpatient setting require prior authorization through American Imaging Management (AIM). 

If AIM does not approve a prior authorization request and a provider wishes to submit a reconsideration request, the ordering provider may contact AIM directly to request a reconsideration.  The ordering provider has 180 days from initial denial determination to seek reconsideration of the pre-service authorization denial.  Another physician of like or similar specialty will perform the review. 

If AIM requires additional information from the provider, they will send a Lack of Information (LOI) letter to the ordering provider requesting supporting documentation.  The provider has fourteen (14) days to provide the requested information.  If AIM does not receive the requested information within the fourteen (14) calendar days, the review will be closed and the prior authorization denial will stand.    The determination will be rendered within fourteen (14) calendar days of receipt of all information from the provider.  AIM will issue a letter of determination. 

Reconsideration requests are managed through the AIM Call Center.
          AIM Call Center
          1-866-714-1105

Urgent Reviews
AIM will respond to urgent requests within 72 hours.

Post Service – Pre Payment Claim Review
If the servicing provider is contracting with Blue Cross of Idaho and fails to check for a prior authorization, proceeds with the study and bills for the service, the claim will receive a denial upon claim adjudication for lack of prior authorization. For non Blue Cross of Idaho contracting providers, the claim will pend for AIM retrospective medical necessity review.  AIM will request supportive documentation from the Ordering Provider.  If the documentation is not received by AIM within fourteen (14) calendar days, the review and pended claim will be denied as insufficient clinical information to determine medical necessity.

Post Service - Post Payment Provider Inquiry
If the servicing provider wishes to inquire or dispute the claim denial, please follow the appeals process through Blue Cross of Idaho as stated in MA PAP229.

If the claim denial is due to lack of prior authorization, the provider’s authorization history is reviewed to determine compliance with contractual requirements.  The privilege of a post service medical necessity review will be extended to those providers who commonly follow prior authorization requirements.  If a provider demonstrates consistent patterns of failing to obtain authorizations, that provider may not be granted a retrospective medical necessity review.


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