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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

November 2018

Medicare Advantage: Cardiac Prior Authorization Program

For dates of services beginning Jan. 1, 2019, Harvard Pilgrim will require prior authorization for Medicare Advantage members for the following non-emergent cardiac diagnostic tests and interventional procedures through National Imaging Associates, Inc. (NIA):

  • Cardiac Resynchronization Therapy (CRT)
  • Implantable Cardioverter Defibrillator (ICD)
  • Pacemaker Insertion
  • Transthoracic Echocardiography (TTE)
  • Transesophageal Echocardiography (TEE)
  • Stress Echocardiography
  • Heart Catheterization

This is in addition to cardiac studies that are currently part of our existing diagnostic imaging authorization program with NIA, including cardiac computed tomography angiographies (CCTA), multi-gated acquisition (MUGA) scans, and myocardial perfusion imaging (MPI)/nuclear stress tests.

About the program

The primary aim of the program is to promote the optimal use of diagnostic modalities in the assessment and treatment of cardiac diseases, with a focus on minimizing radiation exposure for patients through the use of the most efficient and least invasive testing options available. Program components include:

  • Evidence-based clinical guidelines and proprietary algorithms to support clinically appropriate diagnostic options for each patient
  • Consultations with cardiologists with expertise in elective cardiac diagnostic imaging and interventional procedures when peer-to-peer review is required

For complete details, please refer to NIA’s clinical guidelines and the Utilization Review Matrix for coding information.

Requesting authorization and submitting claims

Ordering physicians may request authorization via the NIA website (www.RadMD.com) or by phone at 800-642-7543. NIA will begin accepting authorization requests on Dec. 18, 2018. Providers can check on the status of their authorization requests easily through www.RadMD.com (log in and select the “My Exams Requests” tab).

Please continue to send claims directly to Harvard Pilgrim as you do today (see the Claims section of our StrideSM (HMO) Medicare Advantage Provider Manual).

To ensure appropriate reimbursement, it is important that the rendering provider/facility confirms that authorization has been obtained prior to performing the procedure, as Harvard Pilgrim will deny payment if any of the above listed cardiac studies are performed without prior authorization. Members cannot be balance billed for such procedures.

Sign up for a webinar

NIA is offering educational webinars for providers who would like more information on this program and the authorization process:

  • Tuesday, Dec. 4 at 8 a.m. and noon EST
  • Wednesday, Dec. 5 at 8 a.m. and noon EST
  • Tuesday, Dec. 11 at 8 a.m. and noon EST
  • Wednesday, Dec. 12 at 8 a.m. and noon EST

To register for one of these sessions, please email NIAWebinar@magellanhealth.com at least one week prior, and include the name “Harvard Pilgrim,” as well as the webinar date, your group name, TIN, address, phone number, fax number, and number of participants attending. Please refer to this webinar flyer for complete details on how to sign up for and log into one of these educational sessions.

Resources to assist you

For more information on this change, please refer to the following provider education materials:

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