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

November 2018

Prior Authorization for Cervical Spine Procedures


Harvard Pilgrim is expanding our existing musculoskeletal (MSK) prior authorization program with National Imaging Associates, Inc. (NIA) to include non-emergent inpatient and outpatient cervical spine surgeries for commercial and Medicare Advantage members. Effective for dates of service beginning Jan. 1, 2019, prior authorization is required for the following cervical spine surgeries and their associated allowable billed groupings:

  • Cervical anterior decompression with fusion — single (22551) and multiple levels (22552)
  • Cervical posterior decompression with fusion — single (22600) and multiple levels (22595)
  • Cervical anterior decompression without fusion (63075)
  • Cervical posterior decompression without fusion (63045)

Please refer to NIA’s clinical guidelines and the Utilization Review Matrix for Interventional Pain Management and Musculoskeletal Surgery for complete 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 (for more information on claims submission, see the Billing and Reimbursement section of Harvard Pilgrim’s commercial Provider Manual or the Claims section of our StrideSM (HMO) Medicare Advantage Provider Manual).

To ensure appropriate reimbursement, it is important that the rendering surgeon/facility confirms that authorization has been obtained prior to performing the procedure, as Harvard Pilgrim will deny payment for non-emergent cervical spine surgeries performed without prior authorization. Members cannot be balance billed for such procedures.

Resources to assist you

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

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Network Matters Archives

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HPHCURRENT EVENTS

Harvard Pilgrim Regional Network Meeting: Manchester NH Kickoff Event

CLINICIAN CORNER

Prior Authorization for Cervical Spine Procedures

Medicare Advantage: Cardiac Prior Authorization Program

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Updates on Medical Drugs Obtained Through Specialty Pharmacy

Billing Monitored Anesthesia Care Policy for Screening Colonoscopies for Commercial Members

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Update to Reimbursement Process for Observation to Inpatient Transition

Modifier SA for Reporting on Behalf of Non-Physician Practitioners

PUBLICATION INFORMATION

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator