Outpatient Radiology Prior Authorization
Provider Administrative Policy
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
AIM Specialty Health® (AIM), a specialty benefits management organization, manages Blue Cross of Idaho's prior authorization requests for advanced imaging services. We contract with AIM to manage use of high-technology outpatient advanced imaging services offered as part of our specialty benefits management program.
Blue Cross of Idaho commercial and Medicare Advantage members require prior authorization before receiving advanced imaging procedures. Prior authorization is not required for groups listed on the Advanced Imaging page at bcidaho.com. To view the list, follow the below steps:
- Go to bcidaho.com
- Log onto the secure provider portal
- Select Advanced Imaging
- Select Advance Imaging again
- Select Groups NOT Participating
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 services is part of an acute inpatient or skilled nursing stay, observation care, or occurs during an emergency department visit.
Effective November 1, 2014, echocardiography is also an imaging service requiring prior authorization.
Registration is required on OptiNet for providers who offer sleet testing and therapy services, including durable medical equipment (DME) suppliers, for Blue Cross of Idaho members. Each location where these services are offered requires separate registration. Ordering physicians can choose a servicing provider from the on-line directory based on their ability to provide home sleep testing, facility-based sleet testing and DME services.
The registration tool is available through Blue Cross of Idaho provider portal at bcidaho.com. OptiNet allows you to complete the registration at your convenience, and it can be started, paused and saved as necessary.
Submission of Requests for Advanced Imaging Services
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.
To submit your request for prior authorization, you may contact AIM:
- Through the Blue Cross of Idaho provider portal at bcidaho.com, available 24-hours/day, 7 days/week, or;
- By calling 866-714-1105, available Monday-Friday, 8 a.m. - 6 p.m. Mountain time
Failure to obtain prior authorization will result in a claim denial.
Blue Cross of Idaho providers (ordering and servicing) 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 participation providers to obtain authorization pror 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 a 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 refer to PAP263 for a comprehensive list of scenarios which would qualify for a retrospective medical necessity review of services that did not receive prior authorization. Inquiries and appeals in these cases will only be accepted when submitted with evidence of why the prior authorization was not obtained.
- 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 offer 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 a prior authorization.
- If neither the ordering nor the servicing providers are 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 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 866-714-1105.
- 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 CMS1500 form
- Field 63 of the UB-04 form
- Go to bcidaho.com
- Log on to the secure provider portal
- Select Advanced Imaging
- Follow the instructions outlined 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 Specialty Health Utilization Management staff:
- Name and office phone number or ordering physician
- Member name, date of birth and identification number
- Requested examination (CPT® code is not required, but is helpful - unlisted CPT codes cannot be used). If not CPT® code is available, please be as specific as possible; identifying body part and exam.
- 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, CTs lab work, ultrasound, scoped procedures, referrals to specialists, specialist evaluation,
- Reason the study is required (i.e., further evaluation, rule out disorder)
If requested by AIM, please have the following documents ready to fax. AIM will provide you with the fax number to use:
- Clinical notes
- X-ray report
- Previous CT/MRI report
- Specialist reports/evaluations
- Ultrasound reports
If a peer-to-peer review is required, 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. Please adhere to the required 24-hour turn-around time and include the clinical information requested by the AIM physician reviewer.
For specific guidelines about these procedures, please refer to the AIM Specialty Health website located on the provider portal at bcidaho.com and select Clinical Guidelines.
Blue Cross of Idaho and AIM Specialty Health® have developed a matrix for providers listing 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.
Each row represents a family or group of CPT codes, any of which are allowed as an authorized CPT code within that group. 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 codes) or unlisted codes.
Blue Cross of Idaho contracting providers are allowed one level of pre-service appeal. For advanced imaging services, AIM conducts this review on our behalf. You can appeal a denied prior authorization request for an advanced imaging study prior to service by contacting AIM Specialty Health directly at 866-714-1105. Providers may request an appeal within 180 days of receiving a denial letter from AIM. If an appeal is requested through AIM, an appeals coordinator will be assigned to review the case and facilitate correspondence.
Frequently Asked Questions
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 at www.bcidaho.com.
|March 2015||Revised||Added language for peer review, revised CPT matrix and clarified one level of pre-service appeal|
|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|