Medical Specialty Solutions Quick Reference Guide for Providers Form

Blue Cross Complete of Michigan LLC is an independent licensee of the Blue Cross and Blue Shield Association. Evolent (formally National Imaging Associates, Inc.) Medical Specialty Solutions Quick Reference Guide
for ordering and rendering providers Effective: May 1, 2022 Blue Cross Complete has entered into an agreement with National Imaging Associates Inc., a subsidiary of Magellan Health, to manage a suite of Medical Specialty Solutions. The program is consistent with industrywide efforts to both ensure clinically appropriate care and manage increasing utilization of these services. Effective May 1, 2022, the program will require prior authorization from NIA for the following non-emergency outpatient diagnostic imaging services:  CT/CTA  CCTA  MRI/MRA  PET scan  Myocardial perfusion imaging  MUGA scan For a list of the CPT-4® codes that NIA authorizes on behalf of Blue Cross Complete, refer to NIA’s website, RadMD.com to obtain the Blue Cross Complete/NIA Billable CPT Codes Claim Resolution/Utilization Review Matrix. Medical Specialty Solutions services performed in the following settings don’t require authorization through NIA: • Inpatient • Observation • Emergency room or urgent care facility Urgent and emergency care If an urgent or emergency clinical situation exists outside of a hospital emergency room, contact NIA immediately with the appropriate clinical information for an expedited review. NIA’s website RadMD.com can’t be used for urgent or emergency clinical situations during normal business hours. For prior authorization of urgent or emergency care during normal business hours, call NIA at 1-800-424-5351.

Blue Cross Complete NIA Provider Quick Reference Guide - Page 2 of 4 Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference, Blue Cross Complete doesn’t control these sites and isn’t responsible for their content. Obtaining authorizations The ordering provider is responsible for obtaining prior authorizations for the Medical Specialty Solutions services listed above. The provider rendering services is responsible for:  Ensuring an authorization was obtained. Payment will be denied for procedures performed without a necessary authorization. The member can’t be balance billed for these procedures  Communicating to all personnel involved in outpatient scheduling that prior authorization is required for the above procedures under Blue Cross Complete  Requesting the authorization number (if a provider office calls to schedule a member for a procedure requiring prior authorization)  If the referring provider hasn’t obtained prior authorization when required, advising the provider to obtain an authorization If a member calls to schedule an appointment for a procedure that requires authorization and doesn’t have the authorization number, the member should be directed back to the referring provider who ordered the procedure. Prior authorization process There are two ways to obtain authorizations ― either through NIA’s website at RadMD.com (preferred) or by calling NIA toll-free at 1-800-424-5351. Information needed to obtain prior authorization To expedite the prior authorization process, refer to the specific required documentation for each Medical Specialty Solutions service.+ Have the appropriate information ready before logging into RadMD.com* or calling NIA at 1-800-424-5351. (+Required information)
 Name and office phone number of ordering provider+  Member name and ID number+  Requested procedure+  Name of provider office or facility where the service will be performed+  Anticipated date of service  Details justifying procedure+ • Symptoms and their duration • Physical exam findings • Conservative treatment member has already completed (e.g., physical therapy, chiropractic or osteopathic manipulation, hot pads, massage, ice packs, medications) • Preliminary procedures already completed (e.g., X-rays, CTs, lab work, ultrasound, scoped procedures, referrals to specialist, specialist evaluation)

Blue Cross Complete NIA Provider Quick Reference Guide - Page 3 of 4

*Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference, Blue Cross Complete doesn’t control these sites and isn’t responsible for their content. • Reason the study is being requested (e.g., further evaluation, rule out a disorder)

 Be prepared to provide the following information, if requested:

• Clinical notes

• Specialist reports or evaluation

• Previous related test results • X-ray reports • Ultrasound reports To assist in collecting information for the authorization process, visit RadMd.com* to access the specific Medical Specialty Solutions clinical checklists and tip sheets.

RadMd.com access  It’s the responsibility of the provider ordering Medical Specialty Solutions services to obtain prior authorization through NIA’s website at RadMD.com or by calling NIA.  To get started, visit RadMD.com and click New User in the Sign In area. Select “Physician’s office that orders procedures” from the description drop-down. Complete the application and click Submit when finished. Once your application has been processed, you’ll receive a confirmation email from NIA and an invitation link to create a new password. Don’t share your RadMD login information.
 If a user already has access to RadMD to initiate authorizations, RadMD access will allow users to submit an authorization for any procedures and products managed by NIA.
 You can request prior authorization at RadMD.com by clicking the “Request an exam or specialty procedure including cardiac” link on the main menu. RadMD is available 24 hours a day, seven days a week except when maintenance is being performed.
 Pended requests: If you’re requesting prior authorizations through RadMD.com and your request pends, you’ll receive a tracking number. You’ll then be required to submit additional clinical information to complete the process.  Authorizations status: You can check on the status of prior authorizations quickly by using “View Request Status” on the RadMD.com main menu. In addition to the ability to view clinical documentation received by NIA, users can view links to case-specific communication to include requests for additional information and determination letters.  The “Track an Authorization” feature on RadMD.com* allows users who didn’t submit the original request to view the status of an authorization, as well as upload clinical information. This option is also available on the main menu using the “Search by Tracking Number” feature. A known tracking number is required to use this function.

Telephone access NIA Call Center hours are Monday through Friday from 8 a.m. to 8 p.m. Eastern time. You may obtain a prior authorization by calling NIA at 1-800-424-5351.  NIA can accept multiple requests during one phone call.

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*Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference, Blue Cross Complete doesn’t control these sites and isn’t responsible for their content.

Submitting claims

Claims continue to go directly to Blue Cross Complete. Send claims to the following address: Blue Cross Complete of Michigan
P.O. Box 7355
London, KY 40742-7355

For electronic submission, the Blue Cross Complete facility payer ID is 00210; the professional payer ID is 00710.

Important notes  Authorizations are valid for 60 days from the date of request.
 The NIA authorization number consists of alpha/numeric characters. In some cases, you may instead receive an NIA tracking number (not the same as an authorization number) if your authorization request isn’t approved at the time of initial contact. You can use either number to track the status of the request on the RadMD.com or NIA’s interactive voice response telephone system.
 NIA’s Clinical Guidelines are on RadMD.com under Online Tools/Clinical Guidelines. NIA’s guidelines for Medical Specialty Solutions services were developed from practice experience, literature reviews, specialty criteria sets and empirical data.  An authorization number isn’t a guarantee of payment. Whether the requested service is covered is subject to all of the terms and conditions of the member's benefit plan, including, but not limited to, member eligibility, benefit coverage at the time of the services are provided and any preexisting condition exclusions referenced in the member's benefit plan.
 For RadMD assistance or technical support, email NIA at RadMDSupport@MagellanHealth.com or call 1-800-327-0641.  To educate your staff on NIA procedures and assist with any issues or concerns, contact your NIA area Provider Relations Manager, Meghan Murphy at 1-800-450-7281, ext. 31042 or mamurphy@magellanhealth.com.  The Blue Cross Complete member ID card won’t have any NIA identifying information on it. Blue Cross Complete will redirect calls to NIA for Medical Specialty Solutions services.  For prior authorization and claims payment complaints and appeals, follow the instructions on your denial letter or remittance statement.

CPT codes, descriptions and two-digit numeric modifiers only are copyright 2022 American Medical Association. All rights reserved.