Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

New Options for Affordable Health Insurance

PAP219

Outpatient Radiology Prior Authorization


Provider Administrative Policy

Section
Claims Submission
Policy Date
February 2008
Status/Date
Revised/August 2012
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

American Imaging Management (AIM) Specialty Health, a radiology medical management organization, manages Blue Cross of Idaho`s prior authorization requests for diagnostic imaging services.

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 inpatient care, observation or occurs during an emergency department visit.

Prior authorization is not required for members using Blue Cross of Idaho as a secondary insurance.

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

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

Please note

  • If the rendering/billing provider is contracting with Blue Cross of Idaho, the provider must get 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 rendering provider is, the provider must obtain prior authorization.
  • If both the ordering and the rendering 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.

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

  • Communicate to all personnel involved in outpatient scheduling 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 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

NOTE:  Beginning October 1, 2011, imaging requests for adjacent body parts may result in a peer to peer phone review/discussion between physician at AIM and ordering physician.

Prior Authorization by Phone:
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
  • 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 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 Web site located within the provider portal bcidaho.com and select Clinical Guidelines.

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

First Level
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 Level
Follow the inquiry section of PAP236 and state reason as AIM Specialty Health denial.

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

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

CPT Code Matrix

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 contrast agents, radio pharmaceuticals and supplies.

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).

Nuclear cardiology services that 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
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

Search for Policies

Policy Feedback