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PAP251

Advanced Imaging Pre/Post Service Process


Provider Administrative Policy

Section
Claims Submission
Policy Date
February 2009
Status/Date
Revised/July 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 Appeals

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 request a reconsideration of that determination, the ordering provider may contact AIM directly to request a re-review. The ordering provider has 180 days from the initial denial determination to request a reconsideration of the pre-service denial. Another AIM physician of like or similar specialty will perform the second review and provide a determination within 10 calendar days of receipt of all information from the provider.

If AIM requires additional information from the provider in order to complete the review, they will send a Lack of Information (LOI) letter to the ordering provider requesting supporting documentation. The provider has five days to provide the requested information. If AIM does not receive the requested information within the five calendar days, they will close the review and the prior authorization denial will stand. AIM will issue a letter of determination.

Subsequent Reconsideration - If a provider is not satisfied with the initial reconsideration determination, the provider may submit a second written or faxed reconsideration request with additional supportive documentation to Blue Cross of Idaho's Medical Review Department. Blue Cross of Idaho will issue a reconsideration determination within 10 business days of receiving the subsequent reconsideration request.

A provider cannot exercise appeal rights on behalf of the member without the member's express written authorization. Our determination of the provider's request for reconsideration does not affect the member's appeal rights under his or her policy.

The AIM Call Center manages first level reconsideration requests.  For contact information see PAP100

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

Post Service – Pre Payment Claim Review
If a servicing provider fails to check for a prior authorization, performs the study and bills for the service the claim will pend for AIM retrospective medical necessity review.

* AIM will request supporting documentation from the ordering provider. If AIM does not receive the documentation within five calendar days, they will deny the review and pending claim as insufficient clinical information to determine medical necessity. 

*AIM extends the privilege of a medical necessity review to those providers who commonly follow prior authorization requirements. If a provider demonstrates consistent patterns of failing to obtain authorizations, AIM may not provide that provider a retrospective medical necessity review and may result in non-payment of the claim.

Post Service/Post Payment Provider Inquiry
If the servicing provider wishes to appeal the claim denial, please follow the appeals process through Blue Cross of Idaho as stated in PAP236.


Policy History

Date Action Reason
July 2009 Revised Retrospective review comment added

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