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

December 2015

Reminder: Prior Authorizations for Medicare Advantage via NIA


As a reminder, beginning February 1, 2016, Harvard Pilgrim is expanding our prior authorization requirement for diagnostic imaging services and select spinal surgeries and injections to include our Medicare Advantage StrideSM HMO members residing in Massachusetts, New Hampshire, and Maine. Currently, prior authorization is necessary for these services for our commercial members.

National Imaging Associates, Inc. (NIA) will provide utilization management 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 procedures and spine surgeries listed above. For any of these non-emergent services performed on or after February 1, 2016, reimbursement will be made only if a prior authorization has been 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 procedure.

Tips for submitting your authorization request

The following information may be helpful when submitting your request:

  • NIA will begin accepting authorization requests on January 18, 2016 for dates of service on and after February 1, 2016.
  • You may request prior authorization through the NIA website (www.RadMD.com) or by phone (800-642-7543). 
  • You will need to provide a diagnosis code when requesting prior authorization for the services listed above.
  • Typically, a determination is made within 2 business days after the receipt of request with full clinical documentation. The review process can take longer if NIA requires additional clinical information; having complete information upon initiating a prior authorization request helps minimize turnaround time. If NIA does not make a determination on the authorization request at the time of initial contact, you may receive an NIA tracking number. You can use this number to track the status of your request online (www.RadMD.com) or through an Interactive Voice Response (IVR) telephone system.

For additional information, please refer to the article published in last month’s Network Matters, the Access to Care section of the Medicare Advantage Provider Manual, and the medical review criteria posted to the NIA website. If you have any further questions, please contact Medicare Advantage provider call center at 888-609-0692 (TYY: 711).

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PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

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Editor

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Writer

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Production Coordinator