Does HMSA’s decision to transfer the precertification of advanced imaging scans to National Imaging Associates (NIA) represent a change in HMSA benefits?
No, HMSA benefits for radiology services have not changed. HMSA covers medically appropriate imaging services under all lines of business. This change, which was effective October 16, 2006, is simply an administrative change.
Is precertification required for all radiological procedures?
Effective January 1, 2009, precertification is required for all advanced imaging scans. Precertification requirements have been waived for MRI, MRA, CT, CTA and nuclear cardiology services for selected providers. All ordering physicians are required to precertify functional MRI, PET, CT colonography and CCTA scans (ordered by cardiologists only).
Is precertification required for imaging performed in connection with emergency department visits or observation room confinements?
No. Precertification is required only for outpatient services. Services performed in connection with emergency department visits or observation room confinements, and services rendered on an inpatient basis, do not require precertification.
Who is responsible for obtaining precertification?
The ordering physician is responsible for obtaining precertification, but it is in the best interest of facilities to verify that this has been done.
What kind of response time can the ordering physician expect for his/her precertification request?
In general, if the caller has sufficient clinical information on hand, about 60 – 65 percent of precertification requests can be approved during the initial phone call. On average, phone calls to NIA take about five minutes to complete.
If approval is not given in the initial phone call, NIA will generally issue a determination within two business days. In certain cases, the review may take longer if additional clinical information is required to make a determination.
What is the toll free number for the NIA Call Center?
What are NIA’s Call Center hours of operation?
The Call Center is open from 6 a.m. to 6 p.m., weekdays, Hawaii time.
Should precertification take place before scheduling an appointment with the facility to perform the services?
Yes, the precertification process should be completed before the ordering physician schedules the patient for the procedure. Facilities are advised to schedule patients only when they have confirmed that precertification has been given.
What should I do if services are needed on a weekend or holiday?
In urgent, emergent situations, HMSA recommends that services be performed as ordered. However, the ordering physician should contact NIA for retroactive precertification on the following business day. Nonurgent outpatient procedures should be precertified in advance.
What information does the ordering provider need to expedite a call to NIA?
The caller will be asked for the following clinical information:
- Patient history and diagnosis
- Reason for the study
- Results of previous imaging studies
- History of medical or surgical treatment
Can NIA precertify more than one planned procedure in a single phone call?
Yes, a physician may call with multiple precertification requests. Many offices find it easiest to batch information about all the cases that must be precertified and call NIA once a day.
Will NIA issue one precertification number to cover two separate tests performed on the same date of service for the same patient?
No. Each test must have its own precertification number.
Will precertification be required when HMSA is not the patient’s primary coverage?
Precertification is still required when another carrier is primary to HMSA, but precertification is not needed when Medicare is primary to HMSA.
What if my office staff forgets to call NIA and goes ahead to schedule an imaging procedure requiring precertification?
It is important that office staff be trained about the precertification process. In some cases, the facility may remind them to call NIA before they will schedule the procedure. But if a facility does not verify that precertification was given and proceeds with one of the specified procedures, the claim for the service may be denied and the member may not be billed for denied charges for services that are not deemed to meet HMSA criteria for coverage.
If two authorization numbers are associated with the patient encounter, which one should be printed on the claim?
Either of the two numbers may be printed on the claim form. The precertification number that does not appear on the claim form will be captured internally within HMSA’s claims processing system.
Why does NIA ask for a date of service when I can’t schedule the procedure until I receive precertification?
At the end of the precertification process the NIA representative will ask for the name of the facility that will be performing the test and for an approximate date of service. The date of service does not need to be exact.
How long is the precertification number valid?
The precertification approval will allow for a window of 30 days, beginning with the date of determination, during which the service must be performed. If the service does not take place within the approved time frame, please call NIA to update the precertification.
Can the rendering facility obtain precertification in the event an urgent test is needed?
A facility can contact NIA to begin the process, and NIA will follow up with the ordering physician to complete the process.
If NIA denies precertification of an imaging study, does the ordering physician have the option to appeal the decision?
Yes, there is an appeal procedure that is explained in NIA denial letters. If NIA makes the decision to deny the request at the end of the telephone call and the physician does not agree with NIA’s determination, the physician may appeal the decision at that time.
How are procedures that do not require NIA precertification handled?
These procedures will continue to be handled as they are today.
Is there a way to bypass the NIA recorded announcement?
Yes, you may press “1” to initiate a new request for precertification, or press “2” for the status of a case about which you previously called.
How can a facility access information on an approved precertification?
Precertifications can be viewed on at www.RADMD.com. On the right side of the home page is a section where a facility may log on and check the status of a precertification. The facility may search based on the patient’s HMSA number or, if known, by the precertification number.
Are there clinical guidelines?
Yes, clinical guidelines developed by NIA have been adapted to meet HMSA’s needs. The guidelines and algorithms will be updated periodically based on information from the latest medical literature, specialty criteria sets and empirical data.
What about the privacy of member information?
NIA is fully certified to handle all of the protected health information (PHI) it receives. HMSA’s Business Associate Agreement with NIA requires that it protect the privacy of HMSA member information.
What will happen if precertification was not requested?
If precertification was not sought or given prior to services being performed, claims will be subject to review. HMSA will seek additional information from the ordering physician and will review the claim based on the information provided. This process will cause claims payment delays.
In addition, if the information provided by the ordering physician does not meet criteria for coverage, benefits will be denied for both the technical and professional components of the study. Neither the facility nor the radiologist may bill the member for the denied services.
What will happen if precertification is denied?
If precertification is denied because the service is determined not to be medically indicated, payment will not be made. The rendering provider 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 Agreement of Financial Responsibility – Medical form prior to services being performed.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |