Point32 Outpatient Advanced Imaging Authorization (PM) Form

Harvard Pilgrim’s radiology authorization program

Harvard Pilgrim’s radiology authorization program is managed through an arrangement with National Imaging Associates (NIA). The following outpatient advanced imaging services are included in the program:

• Computerized Tomography and Computerized Tomography Angiography (CT/CTA)
• Magnetic Resonance Imaging and Magnetic Resonance Angiography (MRI/MRA)
• Nuclear Cardiology
• Positron Emission Tomography (PET)
• Diagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography)

Imaging procedures that are performed as part of hospital emergency room, observation stay, surgical day care/minor surgery or inpatient services do not require NIA authorization.

National Imaging Associates

National Imaging Associates is a nationally recognized leader in managing outpatient radiology services and has both NCQA certification and URAC accreditation. NIA developed clinical guidelines based on practice experiences, literature reviews, subspecialty guidelines, evidence based medicine, consensus review, feedback from payor Radiology Clinical Advisory Committees, expert opinion and empirical data. NIA’s Guidelines for Clinical Use of Diagnostic Imaging can be found on its website, www.radmd.com.

Harvard Pilgrim retains oversight of all activities delegated to NIA.

Action Required-Ordering Provider

The ordering clinician is responsible for completion of the NIA authorization process before scheduling advanced imaging services.

• Authorizations can be requested on-line at www.radmd.com, or
• Contact NIA by telephone at 800-642-7543.
• NIA Call Center hours of operation are Mon.–Fri., 8 a.m.–8 p.m.
• Ordering providers should refer to NIA’s website www.radmd.com, for RadMD registration instructions.
• The planned procedure will be evaluated using NIA’s evidence-based guidelines algorithms.
• A small percentage of cases will include peer-to-peer consultation.

Emergency advanced imaging procedures rendered at a location other than hospital emergency rooms require notification to NIA by the ordering clinician within two business days of the service.

Authorization is not complete until consultation, when required, has been concluded and an approved authorization transaction number has been issued. Failure to complete the authorization process will result in an administrative denial of the claim payment.

Information Required

The following information will be requested from the ordering clinician’s office by NIA and should be available at the time of the call:

• Ordering physician name, office phone, mailing address, fax number
• Office administrative or clinical contact name or direct line/extension number
• Patient’s name, date of birth and Harvard Pilgrim identification number
• Planned examination
• Reason for examination
• Baseline for new treatment
• Evaluation of current therapy or treatment
• Further evaluation
• Rule out disorder
• List of symptoms and their duration
• Conservative treatment (and duration) patient has already completed (such as physical therapy, chiropractic or osteopathic manipulation, massage, medications)
• A valid, specific ICD-10 diagnosis code that represents the indications(s) for which the service is ordered
• Name and address of provider office or facility where the service will be performed
• Diagnosis and clinical information
• Patient history and diagnosis
• Results of previous imaging studies
• History of medical or surgical treatment

Action Required-Servicing Provider (Imaging Facility)

The facility should confirm that the ordering clinician has completed the prior authorization process before providing services by requiring evidence of an approved NIA transaction number.

Harvard Pilgrim HealthCareSTRIDESM (HMO) MEDICARE ADVANTAGE

Harvard Pilgrim Health Care-StrideSM Medicare Advantage Provider Manual5January 2021

• Outpatient advanced imaging procedures should be scheduled only when an approved NIA transaction number is verified.
• If a patient calls to schedule an appointment for a procedure that requires authorization, and does not have the approved NIA transaction number, direct the patient back to the ordering clinician.
• If an imaging facility conducts an advanced imaging procedure for which authorization was not completed, the procedure will not be reimbursed and the member cannot be balance billed.
• If an emergency advanced imaging procedure is requested at a location other than a hospital emergency room, the imaging facility can call NIA to start the notification process. NIA will outreach to the ordering provider to obtain clinical information to complete the authorization.

NIA Response

When the process is completed, an approval transaction number will be given to the caller. (If the request is approved NIA will offer to transfer the caller to the imaging facility to schedule the procedure.) A confirmation fax will automatically be sent to the ordering clinician; if the request is approved, confirmation will also be faxed to the imaging facility. NIA will also send written confirmation of approval and denial decisions to the member.

The approval will contain the following information:

• Approved transaction number (ex. NIV12345)
• Planned procedure
• Imaging facility
• Date of service, if known (The approved transaction number is active for 31 days from the date of service, if known, or 31 days from the completion of the notification process.)

Denial letters will contain information needed to assist the member in understanding the denial, and deciding whether or not to appeal the decision, including:

• The specific reason(s) for the denial, including clinical justification of the decision (consistent with generally accepted standards of medical practice); discussion of the individual member’s presenting symptoms or condition, diagnosis, and treatment interventions; and specific information upon which the adverse determination was based.
• The reason(s) that criteria were not met, including a reference to the benefit provision, guideline, protocol, or other criterion on which the denial was based, and notification that the member can obtain a copy of the actual information on which the denial was based.
• Any alternative treatment options offered by Harvard Pilgrim.
• The date that written or electronic confirmation was sent.
• Instructions as to how the member and/or physician can obtain a copy of the criteria used to make the determination.
• A description of appeal rights, including the right to submit written comments, documents, or other information relevant to the appeal; and an explanation of the appeal process including the right to member representation and timeframes for deciding appeals.

Harvard Pilgrim HealthCareSTRIDESM (HMO) MEDICARE ADVANTAGE

Harvard Pilgrim Health Care-StrideSM Medicare Advantage Provider Manual6January 2021

Status Inquiry Electronic

Servicing providers can use NIA’s electronic channel to determine if authorization has been completed through NIA’s website, www.radmd.com.

• Refer to NIA’s website, www.radmd.com, for RadMD registration information.

Phone Option

Providers may check the status of radiology authorization requests by phone, 24 hours a day, 365 days a year, at 800-642-7543 — select option 2 from the main menu. This service is specifically for status inquiries only.

Notification Changes

NIA must be notified by telephone if any change to the original authorization occurs, such as a change to the procedure, a change to the imaging facility or a change to the date of service (if the new date of service exceeds the original 31-day date range validity period).

Records in RadMD cannot be edited.

Retroactive Notification After Hours

If a procedure is both scheduled and performed by a servicing facility outside of NIA’s business hours (Mon.–Fri., 8 a.m.–8 p.m.), the facility must notify NIA within two business days. If the request for authorization is made within two business days, the claim will not deny for failure to notify in advance.

Additional Procedures

If the radiologist identifies a need to extend an imaging examination to a contiguous body area, the servicing facility should notify NIA of the extended study. NIA will update the authorization record to include the extended examination. The claim will not deny for failure to notify in advance.