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PAP219

Outpatient Radiology Prior Authorization


Provider Administrative Policy

Section
Claims Submission
Policy Date
February 2008
Status/Date
Revised/January 2015
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

Outpatient Radiology Prior Authorization

AIM Specialty Health® (AIM), a specialty benefits management organization, manages Blue Cross of Idaho`s prior authorization requests for advanced imaging services. Blue Cross of Idaho contracts with AIM to manage utilization for high-technology outpatient advance imaging services offered as part of our specialty benefits management program.

Prior authorization is not required for groups listed on the Advanced Imaging page of bcidaho.com. Prior authorization is also not required for enrollees using Blue Cross of Idaho as a secondary insurance.

See PAP100 for AIM Specialty Health contact information.

MRI/MRA, CT, PET and nuclear cardiology scans require prior authorization unless the service is part of an inpatient skilled nursing stay, observation care or occurs during an emergency department visit.

Effective November 1, 2014, echocardiography was also added to the list of imaging services requiring a prior authorization.

Prior to scheduling an appointment for a non-emergent MRI/MRA, CT, PET, nuclear cardiology or echocardiography scan, ordering physicians must obtain authorization through AIM by using either the provider portal on the Blue Cross of Idaho`s website, bcidaho.com or by calling AIM Specialty Health`s toll-free number (see PAP100). Failure to get prior authorization could result in a claim denial.

Blue Cross of Idaho providers have up to seven (7) days after the date of service to request a retrospective authorization through AIM for advanced imaging services, nuclear cardiology and echocardiography. Although seven (7) days is allowed for a post service review, we strongly encourage participating providers to obtain authorization prior to administering services.

AIM only accepts retro-authorization requests by phone at 866-714-1105.

AIM will deny authorization requests that are more than seven (7) days past the date of service and will not review them for medical necessity. Blue Cross of Idaho will also deny the resulting claim for lack of authorization. Neither AIM nor Blue Cross of Idaho will perform medical necessity reviews retrospectively upon provider inquiry or appeal, unless the provider presents a compelling circumstance explaining the lack of prior authorization. Possible scenarios include:

  • If a provider indicates the patient presented the wrong insurance card and the provider was not aware the patient had Blue Cross of Idaho. (This may occur with new enrollees or if the enrollee hasn't visited the practice in question since his or her new enrollment).
  • If a provider is new Blue Cross of Idaho contractor and has only seen a small volume of Blue Cross of Idaho enrollees.
  • If a provider presents a remittance advice from another insurance carrier demonstrating an assumption that another payer was primary.

If you failed to obtain an authorization and provided services more than seven (7) days ago, please follow the Inquiry and Appeal process outlined in PAP236. As stated above, inquiries and appeals for lack of authorization will only be accepted when submitted with evidence of why the authorization was not obtained. See PAP236 for guidance.

Please note

  • If the servicing/billing provider is contracting with Blue Cross of Idaho, that provider must obtain the prior authorization. 
  • Blue Cross of Idaho contracting mobile providers who provide services in a contiguous county must also obtain prior authorization.
  • If the ordering provider is not a Blue Cross of Idaho contracting provider but the servicing provider is, the servicing provider must obtain prior authorization.
  • If both the ordering and the servicing providers are not Blue Cross of Idaho contracting providers, the provider does not need prior authorization, but services may be subject to medical necessity review.

As a servicing service provider, to ensure that you obtain accurate authorization numbers, please consider the following:

  • Communicate to all personnel involved in outpatient scheduling that MRI/MRA, CT, PET, nuclear cardiology and echocardiography 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 the provider of this requirement and advise the provider to complete authorization online or contact AIM Specialty Health at the toll-free number (PAP100).
  • If a patient calls to schedule an appointment for an unauthorized procedure, direct the patient back to the ordering physician.
  • If the ordering physician writes a prescription for the patient, the physician should write the authorization number on the prescription.
  • Include the authorization number on claims. If you received multiple authorization numbers, only one is required on the claim.
    – Field 23 of the a CMS 1500 form
    – Field 63 of the a UB-04 form

On line Authorizations

  1. Log on to the secure provider portal
  2. Select Advanced Imaging
  3. Follow the outlined instructions by AIM Specialty Health

Prior Authorization by Phone:
AIM's toll-free number is 866-714-1105. Please have the following information ready for 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 services are provided. If this is unknown at the time of service or the location is changed, it is helpful to notify AIM Specialty Health when scheduling services.
  • Anticipated date of service (if known)
  • Details justifying examination
  • Symptoms and duration
  • Physical exam findings
  • Conservative 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 study 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 Specialty Health website located within the provider portal bcidaho.com and select Clinical Guidelines.

A list of frequently asked questions can be located under the Advanced Imaging link on the provider portal of the Blue Cross of Idaho website bcidaho.com.

 

CPT Code Matrix

Blue Cross of Idaho and AIM Specialty Health® have developed a matrix for providers listing the CPT® codes requiring prior authorization through AIM. The linked matrix contains all the CPT codes AIM Specialty Health manages on behalf of Blue Cross of Idaho.

The Group Default CPT Code column represents the parent code for the code groupings. If there is an authorized group default CPT code, we will reimburse one of the listed procedure codes under the code grouping when submitted on a claim. This assumes the application of appropriate billing rules and the service performed within the date of service validity period. The matrix does not include codes representing CPT-add on codes, contrast agents, radio pharmaceuticals and supplies. Reimbursement of these associated services will be made based on approval of the primary procedure.

If the matrix does not list a family or group of CPT codes, an exact match is required between the authorized CPT code and a submitted CPT code on the claim.

The matrix does not include codes submitted by facilities using CMS Outpatient PPS coding (HCPCS C codes).

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

First Attempt (through AIM)

The ordering provider or staff member may contact AIM Specialty Health directly or request an appeal within 180 days of receipt of the denial letter. Once the provider receives a denial letter, the ordering physician or an office staff member can discuss any additional medical information with an AIM Specialty Health physician reviewer by calling 866-972-9842.

Second Attempt (through Blue Cross of Idaho)

Follow the inquiry section of PAP236 and state reason for AIM Specialty Health denial.

Note:  For preservice inquiries/appeals, Blue Cross of Idaho only allows one level of review.

A list of frequently asked questions can be located under the Advanced Imaging link on the provider portal of the Blue Cross of Idaho website bcidaho.com.

 


Policy History

Date Action Reason
January 2015 Revised Added program statement and clarification to review process at AIM and BCI
Augutst 2012 Revised Added vendor's new name
October 2011 Revised Added language regarding peer to peer phone review/discussion.
April 2010 Revised Matrix revised
November 2009 Revised AIM/new matrix
March 2009 Revised Title change and AIM language update
May 2008 Revised New matrix added

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