Facility Role in Providing Technical Services for Procedures Requiring Precertification

1. It is the responsibility of the ordering physician to obtain precertification for imaging studies.
2. It is in the best interest of facilities providing diagnostic imaging services to develop internal processes to ensure that precertification has been obtained, when needed, for the services they provide.
   1. The facility should verify that precertification for outpatient diagnostic imaging has been obtained, when required.
      1. 100% precertification is required for all advanced imaging scans, however, selected physicians have been given waivers from precertification for MRI, MRA, CT, CTA and nuclear cardiology services.
      2. A physician's waiver status may change at any time.
      3. Functional MRI, PET, CCTA (ordered by cardiologists only) and CT colonography scans always require precertification (regardless of a physician's waiver status).
   2. Precertification is not required for advanced imaging services when performed in the emergency department or observation room, or for services performed on an inpatient basis.
3. If more than one procedure requiring precertification is planned, a separate precertification number is required for each procedure ordered.
4. The following suggestions may assist facility staff and prevent denials of claims for services that have not been precertified or of claims for services for which precertification was denied.
   1. Communicate to all personnel involved in outpatient scheduling that precertification is required for all advanced imaging scans. Selected providers have been given a waiver for MRI, MRA, CT, CTA and nuclear cardiology services. All physicians must precertify functional MRI, PET, CCTA and CT colonography scans.
   2. If a physician's office calls to schedule a patient for a procedure requiring precertification, the facility should determine if the physician or service requires precertification by logging on to National Imaging Associates Magellan (NIA Magellan's) website at www.radmd.com
   3. If precertification is required, check for an approved request.
      1. Search RadMD by member name or "View All" requests which will display all approved requests for your facility.
      2. If no approval found, call the ordering physician's office and ask if the request was submitted.
         1. If no request was submitted advise the physician's office of the precertification requirement and advise them to call (NIA Magellan), toll free, at 1-866-306-9729.
            1. The facility may elect to give the provider a tentative schedule for the test, but institute a time period for the physician to call back with the precertification number (e.g., one or two business days), or
            2. The facility may wish to tell the provider that it will schedule the test after precertification has been obtained.
            3. If this is an urgent situation, the facility may schedule the test as soon as possible, but remind the ordering physician that precertification must be obtained the following business day.
         2. If a request was submitted ask for the tracking number of the request.
            1. Log on to www.radmd.com and enter the tracking number to view the status of the request.
5. If precertification is denied because the services are determined not to be medically indicated, payment will not be made. The facility may not bill the member for the denied services, except in cases where the member has been informed of the precertification denial, has agreed to be financially responsible for the charges, and has signed an Acknowledgement of Financial Responsibility - Medical prior to the services being rendered.
6. A precertification number from NIA Magellan does not guarantee HMSA payment. Payment is subject to plan benefits and deductibles, any applicable waiting periods and member eligibility at the time of service.

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