Tuesday, April 5, 2016

PRIOR AUTHORIZATION FOR OUTPATIENT HIGH-TECH IMAGING SERVICES


Tufts Health Plan requires providers to obtain authorization prior to requesting high-tech imaging services in an outpatient setting. Depending on the member’s product, providers must call either National Imaging Associates (NIA) or Cigna.

The following services require prior authorization:
*CT/CTA
**MRI/MRA
**PET Scan
**Nuclear Cardiology

It is the ordering provider’s responsibility to obtain prior authorization before scheduling appointments for Tufts Health Plan members. Rendering providers will need to ensure that all tests for Tufts Health Plan members have the required authorization number before the service is performed. Both professional and technical claims for which there is no authorization number will be denied and the member may not be billed for the service associated with the denied claim.

Note: Diagnostic imaging services performed in the emergency room, observation, and inpatient settings do not require prior authorization. Emergency CT/CTA, MRI/MRA, PET scan or Nuclear Cardiology procedures rendered at a location site other than a hospital emergency room require notification to NIA within two business days of the service.

At this time, the prior authorization program for high-tech imaging services does not apply to CareLink, Uniformed Services Family Health Plan, Tufts Medicare Preferred HMO, Tufts Health Plan Senior Care Options and MCP members.

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