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

November 2015

Prior Authorizations for Medicare Advantage Stride (HMO) via NIA

National Imaging Associates, Inc. (NIA) provides utilization management for outpatient interventional spine pain management procedures, inpatient and outpatient spine surgeries, and outpatient diagnostic imaging services for Harvard Pilgrim’s commercial members. Harvard Pilgrim requires prior authorization on selected spinal surgeries and injections and diagnostic imaging services for these members; effective February 1, 2016, we are expanding this NIA-managed program to include our Medicare Advantage StrideSM (HMO) products.

Prior authorization and reimbursement
For Medicare Advantage Stride (HMO) members residing in Massachusetts, New Hampshire, and Maine, prior authorization will be required for the following:

  • Non-emergent inpatient and outpatient spine surgeries:  lumbar microdiscectomy; lumbar decompression (laminotomy, laminectomy, facetectomy, and foraminotomy); and lumbar spine fusion (arthrodesis); artificial cervical disc replacement
  • Non-emergent outpatient interventional spine pain management services: spinal epidural injections; paravertebral facet joint injections or blocks; paravertebral facet joint denervation [Radiofrequency (RF) Neurolysis]
  • Computerized Tomography (CT)
  • Computerized Tomography Angiography (CTA)
  • Magnetic Resonance Imaging (MRI)
  • Magnetic Resonance Angiography (MRA)
  • Nuclear Cardiology
    Positron Emission Tomography (PET)
  • Diagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography)

Ordering physicians will be responsible for obtaining prior authorization for all of the spine and outpatient diagnostic imaging procedures listed above. Any of these non-emergent services performed on or beyond February 1, 2016, will not be reimbursed if a prior authorization was not obtained. Therefore, to ensure payment of the claim, providers rendering the services listed above should verify that the necessary authorization has been obtained prior to performing the service.

Harvard Pilgrim does not require prior authorization for emergency spine surgery cases that are admitted through an emergency room, spine surgeries outside the scope of those listed above, or diagnostic imaging services provided as part of an emergency room visit or an inpatient admission.

NIA will review authorization requests based on clinical criteria and will issue either an authorization approval number or a medical necessity denial.  Denials will result in a written denial notification letter, mailed to the member with copies sent to the servicing and requesting providers.  Claims that are subsequently submitted for services that did not meet NIA’s clinical criteria for coverage, or for which authorization was not requested, will be denied.

More information
For more detailed information, look to future issues of Network Matters. Prior authorization medical review criteria for policies related to the services managed by NIA can be found on the NIA website. If you have any further questions, please contact Medicare Advantage Customer Service at 888-609-0692 (TYY: 711).

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator