For high technology radiology (HTR) services provided in the elective, outpatient setting, we require prior authorization for most commercial HMO/POS, PPO, and Medicare Advantage HMO and PPO. Carelon Medical Benefits Management (formerly AIM Specialty Health) administers this program on our behalf.
Requirements do not apply to Federal Employee Program members. In addition, prior authorization is not required for any member for HTR studies performed:
Copayments may apply
For some plans, a member may be responsible for a copayment for certain outpatient radiology studies. As always, check eligibility and benefits before rendering service to determine the member’s cost-share for HTR services.
Ordering clinicians should use eligibility and benefit technologies like ConnectCenter—available 24 hours a day, 7 days a week—to determine what’s required for each of their patients.
Perform your inquiry using the Service Type, MRI/CAT Scan.
Below is an example of ConnectCenter eligibility search results.
For these services, we require prior authorization for all commercial and Medicare Advantage members:
Ordering physicians or clinicians must request authorization before the member receives the test (or before performing services). There are three ways to contact Carelon to request prior authorization:
Registration is required for web access. When a new provider joins your group, please make sure that clinician is registered with Carelon.
If you are the contracted provider or facility performing the study:
Prior authorization is valid for 60 days from the date issued. If the member does not receive the approved test within 60 days, the ordering provider will need to submit a new request.
To speed the process, we suggest having this information ready.
Carelon will issue a prior authorization number, or forward the case to a nurse or physician for review. The physician reviewer may contact the ordering provider to discuss the case. Ordering providers may also contact Carelon’s physician reviewer at any time during the process.
Carelon is delegated to conduct individual consideration for certain HTR modalities. Here’s more information about the appeals process for HTR services:
|To:||Submit your appeal to:|
||Carelon Medical Benefits Management
c/o Appeals Department
540 Lake Cook Road
Deerfield, IL 60015
||Blue Cross Blue Shield of MA
P.O. Box 986065
Boston, MA 02298