PRE-CERTIFICATION CHEAT SHEET For any/all questions related to pre-cert call 603-740-2224 & ask for Pre-Cert This is strictly a GUIDE for pre-cert requirements. If an insurance or outpatient test is not listed below, CALL the health plan to verify pre-cert requirements. Include ALL Insurance ID#s & group #s on the order. When an insurance representative states pre-cert is " Not Required " ; document the date & time of the call, the phone # called and representatives name. This is VITAL info to have on the order for billing to appeal if denied; no order will be accepted as valid until this information is provided. IMPORTANT: When a request to change a test is made (by the radiologists protocol); a new auth or updated auth is needed immediately for denial prevention. Example(s): added body part or contrast level change If any insurance states "Auth is not required, but pre-determination is recommended"... the pre-determination must be obtained. These will get denied for no auth or for medical necessity issue at time of billing if not obtained. When using AIM (American Imaging Management) http://americanimaging.net/ or NIA (National Imaging Associates) http://www1.radmd.com/ please be sure you are selecting the correct rendering facility: Wentworth Douglass Hospital with Tax ID: 020260334 and NPI: 1033118104. INSURANCE COMPANY TESTS REQUIRING PRECERTIFICATION CONTACT INFORMATION NOTES AARP n/a n/a MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Caths, Echos, Infusions, Sleep Studies Aetna: 888-632-3862 Auth not required as Medicare supplement policy *Most Aetna plans will give a call reference # for the call Please put that # on the order *Authorization is also required as a secondary insurance including 2nd to Medicare (PFFS aka: Private Fee For Service MRI/MRA, CT/CTA, PET, Nuclear plans are exempt and do not Cardiology, Caths, Echos, Infusions, require authorization) Sleep Studies Aetna: 888-632-3862 *WDH is not in network with Aetna Medicare plans, verify if the patient has out of network benefits before obtaining authorization. American Republic Infusions Use # provided on insurance card APWU Call on all tests Cigna Care Allies: 800-582-1314 Assurant Health Bankers Life MRI/MRA, CT/CTA, PET Health-Health 800-652-4961 *No authorization required when secondary to Medicare. Call for auth on all tests if no auth is required obtain refrence number *No authorization required when secondary to Medicare. *All other tests, call the health plan directly to check pre-cert requirements @800-800-2412 for notification n/a n/a Auth not required as Medicare supplement policy MRI/MRA, CT/CTA, PET, Angio/Cath, Nuclear Cardiology, Echos, Nuclear Medicine, Infusions, Sleep Studies *Call on any/all Anthem BCBS plans not listed by State below *If Anthem States "Auth is not required, but preCall # on back of insurance card for pre- determination is recommended"... the pre-determination cert requirements or call the National must be obtained. These will be denied for no auth/medical phone line @800-676-2583 necessity issues at time of billing if not obtained. Aetna Aetna Medicare BC NATIONAL (Anthem) BC of Alabama BC of Alaska BC of Arkansas including WMW BC of California BC of Colorado BC of Connecticut BC of Florida BC of Georgia BC of Idaho BC of Kentucky BC of Louisiana BC of Maine (Prefix XVB only-exempt no authorization required) MRI/MRA, CT/CTA, PET, Nuclear Cardiology MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos Care Core National: 866-803-8002 *Obtain a reference # from representative if the rep states not required. *For any tests other than those listed call the health plan directly to verify authorization requirements. *AIM Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) *For any tests other than those listed call the health plan directly to verify authorization requirements. AIM (American Imaging Management): 866-666-0776 NIA (National Imaging Associates): 866842-1767 Prefix MRI/MRA, CT/CTA, PET, Nuclear *NIA Authorizes all 3 levels of contrast (with contrast, without Cardiology, Echos, Infusions contrast and with and without contrast) WMW thru AIM: 866-688-1449 *If AIM states auth is not thru them, they will advise you to call the health plan directly please call the number listed on the back of card. *Sleep Studies require auth specifically thru Medical MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos, Infusions, Sleep AIM (American Imaging Management): Management please use the number for providers on the Studies back of the ID card. 877-291-0360 *AIM Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) MRI/MRA, CT/CTA, PET, Nuclear AIM (American Imaging Management): *For any tests other than those listed call the health plan Cardiology, Echos 877-291-0366 directly to verify authorization requirements. *Imaging/Cardiology/Sleep Studies thru AIM (American Imaging *Call the health plan directly for Infusions & Nuc Med Management): 866-714-1107 MRI/MRA, CT/CTA, PET, Nuclear *Sleep Studies require auth thru AIM effective:6/1/13 *Call the health plan directly for Cardiology, Echos, Sleep Studies *AIM Authorizes all 3 levels of contrast (with contrast, Infusions, NucMed Gated Blood Pool without contrast and with and without contrast) Infusions & Nuc Med *NIA Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) *For any NIA (National Imaging Associates): 866- tests other than those listed call the health plan directly MRI/MRA, CT/CTA, PET, Nuclear Cardiology to verify authorization requirements. 326-6302 *Sleep Studies require auth thru AIM MRI/MRA, CT/CTA, PET, Nuclear AIM (American Imaging Management): *AIM Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) Cardiology, Echos, Sleep Studies 866-714-1103 MRI/MRA, CT/CTA, PET, Nuclear AIM (American Imaging Management): *AIM Authorizes all 3 levels of contrast (with contrast, Cardiology without contrast and with and without contrast) 866-714-1105 MRI/MRA, CT/CTA, PET, Nuclear AIM (American Imaging Management): *AIM Authorizes all 3 levels of contrast (with contrast, Cardiology, Echos without contrast and with and without contrast) 888-730-2817 MRI/MRA, CT/CTA, PET, Nuclear AIM (American Imaging Management): *AIM Authorizes all 3 levels of contrast (with contrast, Cardiology, Echos without contrast and with and without contrast) 866-455-8416 *Authorization is required as secondary to Medicare *If AIM states auth is not required thru them it will be required *Imaging/Cardiology/Sleep Studies through the health plan. AIM (American Imaging Management): *Call the health plan directly for Infusions *Sleep 866-714-1107 *Call the health plan Studies require auth thru AIM eff:6/1/13 MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos, Sleep Studies, Sleep directly for Infusions & Sleep PSG *AIM Authorizes all 3 levels of contrast (with contrast, PSG w/MSLT, Infusions without contrast and with and without contrast) w/MSLT (cpt 95805) *** (Authorization guidelines are based on the state the patients PCP resides. Example: if a patient has a Mass HMO policy with a NH PCP the Mass policy will follow NH guidelines for pre authorization see NH guidelines below *** *Authorization is required as secondary to Medicare *If AIM states auth is not thru them: auth will be required BC of Mass HMOthru Medical Management for MA/NH/ME based on (Authorization guidelines are based *Pharmacy (for infusions): 800-366-7778 location of the PCP on the state the patients PCP resides. *Medical Management: 800-327-6716 -Mass Medical Management 800-327-6716 Example: if a patient has a Mass *AIM (American Imaging New Hampshire Medical Management 800-531-4450 HMO policy with a NH PCP the Mass Management):866-714-1107 Maine Medical Management 800-392-1016 policy will follow NH guidelines for pre MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos, Sleep Studies, Sleep *Call Medical Management directly *Infusions call Mass Medical Management directly authorization see NH guidelines below) PSG w/MSLT, Infusions for Sleep PSG w/MSLT (cpt 95805) *Sleep Studies require auth thru AIM eff:6/1/13 BC of Mass Liberty Mutual Plan Prefix LMH only Infusions/Injections BC of Mass PPO Infusions All other tests auth required ONLY if the diagnosis does not meet medical criteria *Medical Management:800-327-6716 listed in the medical bulletin online *Infusions: 800-366-7778 BC of Nebraska MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos, Nuclear Medicine BC of Nevada MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos BC of New Jersey MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos, Nuclear Medicine BC of NH (NH Exchange policies) (Prefixs YGB & YGM exempt as secondary to Medicare) Express Scripts (formally Medco/Accredo) Authorization line 800-753-2851 *Inform the patient they cannot bring in their own medication they may need to give Express Scripts permission to set up delivery with WDH pharmacy. https://www.bluecrossma.com Click on Providers - then click Medical Policies - Enter the medical policy number for one of the following: CT/CTA 009 MRI/MRA 106 - Breast MRI 230 - PET 358 - Nuclear Stress 330 - Ultrasound 007 *AIM Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) AIM (American Imaging Management): *For any tests other than those listed call the health plan 866-745-3265 directly to verify authorization requirements. *NIA Authorizes all 3 levels of contrast (with contrast, without contrast and with and without contrast) *For any NIA (National Imaging Associates): 800- tests other than those listed call the health plan directly 642-2809 to verify authorization requirements. *Obtain tracking # or reference # if representative states no auth required *For any tests other than those listed call the health plan directly to verify authorization requirements. Care Core National: 866-496-6200 *When AIM states patient is not in their system: call Medical Management@ 800-531-4450 to verify who to obtain authorization from. If Medical Management states auth is still required thru AIM Medical Management will initiate a 3 way call with AIM to add the patient back into AIM's system so authorization can be obtained. *Imaging/Cardiology/Sleep/Nuc Cardio *Authorization is required when secondary to ANY other AIM (American Imaging insurance policy including Medicare. *NHN policies with a Maine PCP go thourgh Medical Management):866-714-1107 MRI/MRA, CT/CTA, PET, Nuclear Management Cardiology, Echos, Sleep Studies, Sleep *Infusions & Sleep PSG w/MSLT (cpt 95805,) Medical Management:800-531- *NH Exchange polices follows the same guidlines as BC of PSG w/MSLT, EEG Video 95951, Infusions NH. 4450 BC of North Carolina BC of NY BC of NY (Empire) MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos *Prefix YLA exempt when 2nd to Medicare *Prefix YLS follows United HealthCare MRI/MRA, CT/CTA, PET, Nuclear Guidelines see below Cardiology, Echos BC of NY (Excellus) MRI/MRA, CT/CTA, PET Nuclear Cardiology, Infusions BC of Pennsylvania (Highmark) MRI/MRA, CT/CTA, PET, Nuclear Cardiology BC of Pennsylvania (Independence) MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos, Sleep Studies, Infusions BC of Rhode Island MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos BC of South Carolina (prefix INE included) MRI/MRA, CT/CTA, PET, Nuclear Cardiology BC of Tennessee MRI/MRA, CT/CTA, PET, Nuclear Cardiology BC of Vermont MRI/MRA, CT/CTA, PET, Sleep Studies *If AIM states "not required", they will advise you to call the health plan to check for any other auth requirements *For AIM (American Imaging Management): any tests other than those listed call the health plan directly to verify authorization requirements. 866-455-8414 *NIA Authorizes all 3 levels of contrast with, without and with and without *For NIA (National Imaging Associates): 800- any tests other than those listed call the health plan directly to verify authorization requirements. 642-7820 *Some policies may not require authorization provide the # you called along with the date, time, and name of representative that provided that information. AIM (American Imaging Management): *For any tests other than those listed call the health plan directly to verify authorization requirements. 877-430-2288 *Obtain reference # from Care Core National representative if stated authorization is not required. *For any tests *CareCore National:866-889-8056 other than those listed call the health plan directly to verify authorization requirements. *Infusions: 800-306-0151 *Authorization requirements are policy specific- if NIA states not authorization required through them call the *NIA (National Imaging Associates): 888- health plan to verify 642-4814 *For any tests other than those listed call the health plan directly to verify authorization requirements. *Health Plan: 800-547-3627 *For Sleep Studies call the health plan *If AIM states auth is not required call the health plan directly @ 800-275-2583 and skip the imaging prompt (if you select the imaging prompt you will be routed back to AIM) *Copy and Paste the following link to see additonal tests that *AIM (American Imaging Management): require auth (updated regularly): 866-745-1791 *Health Plan: http://www.ibx.com/pdfs/providers/policies_guidelines/preapp roval/ibc_precert.pdf 800-275-2583 or # on back of ID card *MSI does not authorize all 3 levels of contrastAuthorizations are CPT code specific. *For any tests other than those listed call the health plan directly to verify authorization requirements. MSI (Med Solutions): 888-233-8158 *If NIA states the patient is not in their system call the health plan@ 800-334-7287 or # on back of patients card to verify *NIA (National Imaging Associates): 866- pre-cert requirements. *For any 500-7664 *Health tests other than those listed call the health plan directly to verify authorization requirements. Plan: 800-334-7287 *MSI does not authorize all 3 levels of contrast (w/o with w/wo) - Authorizations are CPT code specific *For any tests other than those listed call the health plan directly to verify authorization requirements. MSI (Medsolutions): 888-693-3211 *Sleep Studies get authorization request form online @ www.bcbsvt.com - Click Provider, then Provider Forms then View Forms click Prior Approval Request & Referral Authorization Form for Medical Services *For any tests other than those listed call the health plan directly to AIM (American Imaging Management): verify authorization requirements. 800-701-0080 BC of Virginia MRI/MRA, CT/CTA, PET, Echos, Nuclear Cardiology BC of WA (Premera) MRI/MRA, CT/CTA, PET, Echos, Nuclear Cardiology *Plan specific - call Medical Management on all tests *For any tests other than those listed call the health plan directly to verify authorization requirements. Medical Management: 800-533-1120 *AIM Authorizes all 3 levels of contrast with contrast without contrast and with and without contrast AIM (American Imaging Management): *For any tests other than those listed call the health plan directly to verify authorization requirements. 866-666-0776 *AIM Authorizes all 3 levels of contrast with contrast without contrast and with and without contrast *For any AIM (American Imaging Management): tests other than those listed call the health plan directly to verify authorization requirements. 800-554-0580 Regence Group Administrators: 866-738- *For any tests other than those listed call the health plan directly to verify authorization requirements. 3924 *Elective procedures need prior authorization Phone: 603-271-5219 *Emergent procedures can be done and auth obtained at later date. Fax: 603-271-4376 BC/BS Regency Group MRI/MRA, CT/CTA, PET, Echo's, Nuclear Cardiology MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos, Infusions Breast & Cervical Cancer Program MRI/MRA, CT/CTA, PET, Nuclear Cardiology Capitol District Physicians Health Plan Everything at WDH requires authorization Phone: 518-641-3700 All Outpatient 800-477-7870 or # on card WDH is out of network with this plan and will need authorization even if the cpt code does not itself need auth. Please obtain auth based on being out of network. *Card states: Certification is mandatory for all hospital confinement or outpatient procedure n/a n/a Auth is not required as out patient. BC of Wisconsin Celtic ChampVA MRI/MRA, CT/CTA, VTI (CPT 77011), PET, Nuclear Cardio, Bone length, Infusions, Sleep Studies (For at home sleep tests please auth 95801 not G0399) **Echo's require medical necessity review (pages 18-23 in the medical policy are the "Not Covered" codes) Cigna ConnectiCare Coventry Health Definity Health EBPA Fallon Federal Blue Cross (prefix R) MRI/MRA, CT/CTA, PET, Nuclear Cardiology MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Nuclear Medicine MRI/MRA, CT/CTA, PET, Nuclear Cardiology *MSI does not authorize all 3 levels of contrast (w/o with w/wo) - Authorizations are CPT code specific *Use the Cigna master precert list online mycignaforhcp.com for auth requirements for all tests other than Imaging & Nuc Cardio or call Cigna directly *VTI cpt code 77011 requires auth thru Cigna directly *Sleep Studies thru CareCentrix eff: February 18, 2013 when requesting authorization for an at home sleep study please use code 95801 no G0399. NON-EMERGENT SERVICES ARE NOT COVERED AT WDH *NIA Authorizes all 3 levels of contrast *For NIA (National Imaging Associates): 877- any tests other than those listed call the health plan directly to verify authorization requirements. 607-2363 *For any tests other than those listed call the health plan Call # on Card directly to verify authorization requirements. *For any tests other than those listed call the health plan 800-344-4203 directly to verify authorization requirements. Infusions Health Plan: 800-578-3272 MRI/MRA, CT/CTA, PET Medsolutions (MSI): 866-879-8317 Health Plan: 866-275-3247 Auth is not required as secondary to Medicare *MSI does not authorize all 3 levels of contrast (w/o with w/wo) - Authorizations are CPT code specific *PPO and Mass Health policies require precert directly through Fallon at 866-275-3247. n/a n/a Auth is not required as out patient. EFFECTIVE 2/17/14 Stress Echos and Diagnostic Heart Cath *Medsolutions (MSI) for imaging & nuclear studies: 888-693-3211 *Cigna direct phone for CT VTI CPT 77011 & Infusions: 800-244-6224 *CareCentrix phone for all sleep studies: 877-877-9899 Fax:866536-5225 or website @ Cigna.SleepCCX.com *Auth is not required as secondary to Medicare *MSI does not authorize all 3 levels of contrast (w/o with w/wo) - Authorizations are CPT code specific *For any tests other than those listed call the health plan directly to verify authorization requirements. *MSI does not authorize all 3 levels of contrast (w/o with w/wo) - Authorizations are CPT code specific *TIP-GWH plans w/the Cigna logo - look the patient up on MSI under Cigna *For any tests other than those listed call the health plan directly to verify authorization requirements. GHI MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Echos Exempt MRI/MRA, CT/CTA, PET, Nuclear Cardiology Great West Healthcare MRI/MRA, CT/CTA, PET, Nuclear Cardiology Medsolutions (MSI): 888-693-3295 MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Infusion, Sleep Studies, CPAP, Nuclear Medicine, Biopsies exempt *Medical necessity review is required for all Echo's, Nuclear Cardiology & Gastric Emptying Scan MRI/MRA, CT/CTA, PET, Nuclear Cardiology *Authorization is also required as a secondary insurance including 2nd to Medicare *Sleep Studies Require auth thru CareCore National @ 888511-0401-Sleep Actigraphy is not a covered test *Authorizations for CPAP(94660) can only be done after *NIA (National Imaging Associates): the sleep study has been preformed. *All 800-642-7543 *CareCore National for Sleep Studies& Echo's,Gastric Emptying Scans (cpt: 78264) and Nuclear CPAP: 888-511-0401 Cardio studies must meet HP's Medical policy *For any tests other than those listed call the health plan 866-940-7373 or # on card directly to verify authorization requirements. GEHA Harvard Pilgrim (HPE & HPK exempt) HCVM HMA Admin Health Net MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Stress Echo, SPEC MRI/MRA, CT/CTA, PET, Angio, Nuclear Cardiology Health New England MRI/MRA, CT/CTA, PET, Nuclear Cardiology Health America (Coventry) Medsolutions (MSI): 866-879-8317 Care Core National: 800-835-7064 NIA (National Imaging Associates): 866- *For any tests other than those listed call the health plan directly to verify authorization requirements. 326-6303 *For any tests other than those listed call the health plan directly to verify authorization requirements. First Health: 800-932-6690 *MSI does not authorize all 3 levels of contrast Authorizations are CPT code specific *For any tests other than those listed call the health plan directly to verify authorization requirements . MSI (MedSolutions): 888-693-3211 Health Plans Dirigo-(prefix HHD only) Sleep Studies & CPAP follow up, Cath/Angio procedures, Infusions… All other test are plan specific call Care Management on each patient Medical necessity review is required for Echo's Care Management: 866-325-1550 *Imaging & Nuc Cardio call NIA (Naitonal Imaging Associates): 800642-7543 *For all other testing call Dirigo MRI/MRA, CT/CTA, PET, Cath/Angio, Nuclear Cardiology, Sleep Studies Directly: 877-213-5225 Health Plans - WDH employees (HHAC4) All Sleep Studies & CPAP follow up, Cath/Angio procedures, Infusions Medical necessity review is required for Echo's Care Management: 866-325-1550 Health Plans Inc *CPAP follow up (CPT94660) can be added to the original sleep study authorization *All Echo's,Gastric Emptying Scans (cpt: 78264) and Nuclear Cardio studies must meet HP's Medical policy. *For any tests other than those listed call the health plan directly to verify authorization requirements . *NIA authorizes all 3 levels of contrast with contrast without contrast and with/without contrast *For any tests other than those listed call the health plan directly to verify authorization requirements . *CPAP follow up (CPT94660) can be added to the original sleep study authorization *All Echo's,Gastric Emptying Scans (cpt: 78264) and Nuclear Cardio studies must meet HP's Medical policy *For any sleep study for WDH Health Plans with a Sleep Diagnosis authorization is required, if the respresentative states no authorization is required please ask them to double check. Humana & Humana Gold MRI/MRA, CT/CTA, PET, Echos, Nuclear Cardiology, Cardiac Cath, Nuclear Medicine, Sleep Studies Keystone Mercy Magna Care All Hospital Services Sleep Studies, Pain Management Mail Handlers MRI/MRA, CT/CTA, PET, Nuclear Cardiology MaineCare Maine Community Health Options (MCHO) Martin's Point/US Family NIA authorizes all 3 levels of contrast (w/o with w/wo) WDH Provider ID #: 30024770 800-410-7778 (Authorization is required as a secondary insurance to commercial payers; not Medicare .) Auth is CPT code specific Infusions, Effective March 1 for ages 21-64: CT, 866-690-5585 PET Out-patient diagnostic testing authorizations are not required as WDH is considered an "in state" facility All patients do not have the same plan w/MaineCare Please call on Infusions as they are plan specific include the reference # on the order . For any CT/PET request you can start submit to MaineCare Feb 3. Infusion Fax:877-314-5693 Diabetes, Dietary, Angio, Rehab Services including pulmonary, Infusions, anything invasive (procedures including biopsies/pic lines, needle aspiration, etc.), Rad-only tomogram injection 888-732-7364 Medicaid - New Hampshire (Please be aware all spend-down patients will not be a part of the managed care plans, these patients guidelines for MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Infusions authorization will not change) MRI/MRA, CT/CTA, Nuclear Cardio Imaging, PET Scans, Cardiac Event Monitors(Holter Monitors Exempt), Well Sense- NHCaid Eff:12/1/2013 Infusions, Sleep Studies, EEG w/CPT (Authorization REQUIRED 2nd to 95951, Echos/Stress Echos, Ultrasound Exempt Medicare) NH Healthy Families- NHCaid Eff:12/1/2013 (Authorization REQUIRED 2nd to Medicare) Health-Help 866-825-1550 Imaging call NIA @ 866-642-9700 All other medical services call Medical Management @ 800-521-6622 877-347-7225 Must verify if the patients specific plan has out of network benefits as WDH is considered out of network with Humana Submit all notifications via completed form on MCHO online . Out-patient Diagnostic authorizations are no longer required p/auto line eff: July 1, 2013 fax all auth requests to Kepro F: 800-922-9847 P: 800-299-5921 (Authorization is required as a secondary insurance to commercial payers; but not required as 2nd to Medicare or Medicare Replacement plans) Dietary consults are not a covered benefit. Authorizations can take at least 48 business hours to process. Status inquires on Schaller Anderson & Kepro authorization: call Xerox P: 866-291-1674 Med Solutions:888-693-3211 Prior Authorization:877-957-1300 Pharmacy:888-566-0008 option 4&2 Contact Med Solutions for any imaging requests. Contact the Prior Authorization line for any other outpatient services. When requesting an outpatient authorization from the Health Plan (not MSI) please request a date range, if a date range is not requested only one date of service will be approved. When requesting authorization for infusion please verify through the Prior Auth line and the Pharmacy line. Please use the Prior Authorization Tool online NH Healthy Families:866-769-3085 MRI/MRA, CT/CTA, Nuclear Cardio, @ http://www.nhhealthyfamilies.com/for-providers/priorNuclear Imaging, PET Scans, Infusions, NIA(National Imaging Associates): 800- authorization/pre-auth-needed/ to determine whether authorization is needed for all other services. Sleep Studies Ultrasound Echos 443-5733 Meritain Health (HCVM) MRI/MRA, CT/CTA, Nuclear Cardio, Nuclear Imaging, PET Scans, Infusions, Home Sleep Studies, Biospies, EEG Video w/CPT 95951 Meridian Health Plan:855-291-5221 Medical Necessity check on the NGS Medical Necessity Review is required website American Health Holding 800-242-1199 or American Health Group 800-847-7605 or MRI/MRA, CT/CTA, PET, Nuclear Cardiology Total 855-452-9998 MVP Healthcare MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Sleep Studies, Infusions Meridian Health Plan- NHCaid Eff:12/1/2013 Medicare NALC Neighborhood Health New Hampshire Health Plans (NHHP) MRI/MRA, CT/CTA, PET, Nuclear Cardiology MRI/MRA, CT/CTA, PET Infusions Northeast Community Care - Arcadia (Medicare Replacement Plan) Authorization is required for everything including lab work. Oxford Health Plans Plan specific Nuclear Cardio, Nuclear Medicine, Infusions Patient Advocates Patriot Healthcare Presbyterian HealthCare Services The Empire Plan Today's Options (PFFS plans exempt) TriCare Prime/Standard - TriCare Health net (TriCare for Life exempt) Contact Health Plan directly for authorization inquiries. See Meridian Prior Authorization Procedures Overview on their website under Provider Manualhttp://www.mhplan.com/nh/providers/index.php?location=pro vider&page=home No authorization required when 2nd to Medicare Auth not required but all outpatient Plan specific - Auth could be thru any one of the companies listed Sleep Study auth's thru SMS www.sleepmanagementsolutions.com MVP: 800-568-0458 Effect 04/01/2012 Imaging authorizations are thru CareCore National: 866-665-8341 CareCore National ** You will need to manually added the Sleeps: Call SMS 888-497-5337 x121 or rendering site giving the WDH address and phone # during website the authorization process until further notice** Auth is not req as secondary to Medicare MSI does not authorize all 3 levels of contrast Authorizations are CPT code specific Part of the Cigna network - look up online or by phone as if Medsolutions (MSI) 888-693-3211 it’s a Cigna plan 800-462-5449 Health Plan :877-888-6447 Auth: 800-367-9938 All other testing is not required as out patient. Non-urgent authorizations can take up to 14 business days. 800-988-3057 Urgent authorizations can take 3-4 business days. Verification of benefits/coverage is needed to see if WDH is Phone # provided on insurance card in network. Out pt diagnostic auth not req unless "Nuclear" is involved in 800-290-8559 the test MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Endo, Cardiac Rehab, Pain Management after 3 visits. MRI/MRA, CT/CTA, PET, Nuclear Cardiology All other tests call the health plan directly MRI/MRA, CT/CTA, PET, Nuclear Cardiology 877-769-7447 MRI/MRA, CT/CTA, PET, Nuclear Cardiology Care Core National:800-420-3471 Today's Options:866-568-8921 Auth not required as secondary to Medicare If CareCore States auth is not required -Call the health plan to make sure they don’t require it directly thru them. Call health plan directly on all other test as it may require auth. Pain, Endo, All other diagnostic tests are plan specific (ie: CT/MR/Sleep…) 877-874-2273 or online https://www.hnfs.net/ ALL forms of TriCare require authorization verification except TrCare for Life. Call or go online prior to scheduling. 800-597-7728 Imaging pre-cert call: Health Help @ 888-318-0280 Health Plan 505-923-7787 Tufts Carelink Tufts Health Plan MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Sleep Studies, Infusions MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Infusions Cigna 800-244-6224 or Medsolutions (MSI) 888-693-3211 Sleep Studies thru CareCentrix - eff: February 18, 2013 NIA 866-642-9703 or # on Card Unicare 866-893-4879 or # on the back of the All tests are plan specific card MRI/MRA, CT/CTA, Nuclear Cardiology, 800-442-9300 or # on card Echo's United Healthcare, Medicare Complete/Solutions, Secure Horizons (PFFS plans exempt) INCLUDE ID# & GROUP# ON ORDER MRI/MRA, CT/CTA, PET, Nuclear Cardiology, Nuclear Medicine, CATH, Infusions, Sleep Studies, Echo's *biospies exempt UHC also has Echo medical policy to check for medical necessity CareCore National 877-773-2884 Cardio/Imaging/Nuc Med call 866-889-8054 Health Plan 877-842-3210 Alternate 800-537-2977 US Department of Labor All tests need approval 850-558-1818 VA Medical (NH) All tests need approval 603-624-4366 UMR Workman's Compensation All tests need approval Call adjuster or nurse case manager at the W/C Insurance Company Policy specific, you may need to call # on back of card to find out if auth is thru Medsolutions or Cigna MSI does not authorize all 3 levels of contrast (w/o with w/wo) Authorizations are CPT code specific CareCentrix p 877-877-9899 f 866-536-5225 or website @ Cigna.SleepCCX.com NIA authorizes all 3 levels of contrast (w/o with w/wo) You will need to obtain a benefits fax before you are able to speak with a representative. The fax will also tell you if authorization is required for Outpatient tests. Not required as secondary to Medicare Group # is required for pre-cert inquiries United Healthcare: Authorization is REQUIRED as secondary to Medicare (UHC group # 310000 exempt) AARP Medicare Complete/Solutions/Secure Horizons are policy specific - call on each plan. Options on the Cardio/Imaging/Nuc Med line 866-889-8054 have changed - please listen carefully Obtain ref/case # when a case has been started and turns out that auth is "not required". UHC does not authorize all 3 levels of contrast; Authorizations are CPT code specific Sleep Studies & Infusions are plan specific call Health Plan directly Call to verify correct date of injury (DOI) that matches the correct injured area/body part and if authorization is required. You will need the patients claim # or social security # with the DOI in order to obtain information or auth. Call to verify correct date of injury (DOI) that matches the correct injured area/body part. Ask adjuster or nurse case manager if the claim is open, on file and if authorization is required. W/C Claims w/patients working in the state of NH generally do not require authorization. Always obtain authorization from the patients medical insurance as back up incase the W/C Claim is denied. 4/24/14 KB Call 603-740-2224 and ask for a Pre-cert Representative for any/all questions
© Copyright 2024 ExpyDoc
