Prior Authorization/Notification Information - Radiology Management Program

Radiology Management Program Prior Authorization

The Prior Authorization component of Highmark's Radiology Management Program will require all physicians and clinical practitioners to obtain authorization when ordering selected outpatient, non-emergency, diagnostic imaging procedures for certain Highmark patients (This authorization requirement doesn't apply to emergency room or inpatient scans). Such tests include select CT scans, select MRI and MRA scans, PET scans and Myocardial Perfusion Testing.

Radiology Management Program Prior Notification

As of September 1, 2010 the Prior Notification component of Highmark's Radiology Management Program will require all physicians and clinical practitioners to obtain prior notification when ordering stress echocardiography. (This authorization requirement doesn't apply to emergency room or inpatient scans).

Authorization numbers will be issued for procedures requiring prior authorization/notification and will be required to ensure appropriate reimbursement.

The "Prior Authorization/Notification Reference Guide" contains all of the details you'll need to know about prior authorization/notification from the perspective of the physician ordering the imaging service. Please review this material and be prepared to contact NIA Magellan - the imaging management firm that is supporting the program - before ordering the select diagnostic imaging procedures.

How to Request Prior Authorization/Notification

Using NaviNet is the preferred way to request prior authorization/notification from NIA.

If you do not yet have NaviNet, you may request authorizations/notifications by contacting NIA via telephone at the toll-free number listed in the "Prior Authorization/Notification Reference Guide."

• Prior Authorization/Notification Reference Guide (Revised September 30, 2016)

Clinical Validation of Records (CVR)

Effective Oct. 3, 2016, Highmark has implemented a Clinical Validation of Records (CVR) process for all codes that are part of the Radiology Management Program. The CVR process will include the request and review of clinical information by NIA.

• CVR Summary Guide

Additional Resources

• Prior Authorization Quick Reference Guide for Ordering Providers

• Radiology Management Program Cardiac Prior Authorization Checklist

• Radiology Management Program Cardiac Prior Authorization FAQs

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