We privilege providers who perform diagnostic imaging services.
To receive reimbursement, all professional providers, technical providers, and non-hospital-based free-standing facilities must have privileges for the following diagnostic imaging services:
- Angiography
- Bone densitometry
- Cardiac CT Scan
- Endovenous laser treatment
- Fluoroscopy
- Mammography
- MRI
- Nuclear Medicine, including PET scan
- Ophthalmic B scans
- Ultrasound (general, breast, vascular, thyroid)
- X-ray
We apply separate and distinct reimbursement criteria to technical providers—who perform imaging services—and professional providers—who read and interpret the images.
| Technical services providers: | Perform imaging services for modality-specific procedure code ranges for the equipment used. |
| Professional services providers: | Perform interpretations for procedure code ranges specific to their specialty and medical training. |
Once you are credentialed and enrolled with us, if your credentialed specialty is on the list of privileged specialties and modalities, you are privileged only for those codes associated with that specialty and do not need to complete a professional privileging application.
If you want to use a code (from the list) that is not associated with your credentialed specialty, submit the Exception Request Form and the applicable associated documents.
| ACR | American College of Radiology |
| AIUM | American Institute of Ultrasound Medicine |
| CPT | Current procedural terminology |
| EVLT | Endovenous laser treatment |
| IAC | Intersocietal Accreditation Commission |
| MRI | Magnetic resonance imaging |
| PET | Positron emission tomography |
| RCP | Radiation control program certificate through the Department of Public Health |
- You can apply to be reimbursed for costs for owning, leasing, or use of diagnostic imaging for the services listed below.
- Complete a separate application for each location where you own, lease, or otherwise incur the full usage cost of diagnostic imaging equipment for any of the modalities listed below.
- If there are changes to the diagnostic imaging equipment or service site information, submit a new copy of the application with an explanation attached.
For the modalities below, use the Limited Technical Privileging Application:
| Modality | Technical requirements |
|---|---|
| Obstetrical ultrasounds (limited/follow-up) | Codes 76815 and 76816 |
| Ophthalmic A scans | Codes 76511 and 76516 |
| X-ray | See page 7 of the TDI Privileging Application |
For the following modalities, use the TDI Privileging Application:
| Modality | Technical requirements |
|---|---|
| Angiography | Specific criteria will depend upon CPT codes you want to perform |
| Bone densitometry | Registration from Massachusetts DPH Radiation Control Program |
| Cardiac CT scan | Accreditation from the American College of Radiology or the Intersocietal Acred. Comm. of Computerized Tomography (IAC CT) |
| Endovenous laser treatment | Free-standing facility and hospitals Accreditation from IAC |
| Fluoroscopy | See list |
| Mammography | Accreditation (or application for accreditation) from IAC or ACR mammography program |
| Magnetic Resonance Imaging (MRI) | Accreditation from IAC or ACR |
| Nuclear medicine (including nuclear cardiology and PET scans) |
|
| Ophthalmic | No requirements, but contract needed |
| Ultrasound, breast | Accreditation from either AIUM or ACR |
| Ultrasound, general |
|
| Ultrasound, thyroid | See Diagnostic Head and Neck Ultrasounds for Evaluation of Thyroid and Parathyroid Disorders |
| Ultrasound, vascular | Accreditation from IAC or ACR |
You can apply to be reimbursed for diagnostic imaging interpretation for the services listed below.
For the following modalities, use the Diagnostic Imaging Professional Privileging Application.
| Modality | Professional requirements |
|---|---|
| Angiography | Specific criteria will depend upon CPT codes you request performing |
| Bone densitometry | Board certified in an approved specialty |
| Cardiac CT scan | Please see Consensus Criteria Permitting a Radiologist to Officially Interpret Cardiac CT (CCT) Studies |
| Fluoroscopy | Board certified and yearly attendance at a fluoroscopy safety course
|
| Magnetic Resonance Imaging (MRI) | Board certified in an approved specialty and/or letter of inclusion in accreditation process |
| Mammography | Board certified in an approved specialty
|
| Ophthalmic | Board certified in an approved specialty |
| Other interventional | Specific criteria depends upon the CPT code requested |
| Ultrasound, general | Board certified in an approved specialty |
| Ultrasound, thyroid | Board certified in an approved specialty (for training criteria, see Diagnostic Head and Neck Ultrasounds for Evaluation of Thyroid and Parathyroid Disorders) |
| Ultrasound, vascular | Board certified in an approved specialty |
| X-ray | Board certified in an approved specialty |
For these modalities, use the applications shown in the right column:
| Modality | Professional requirements | Application to submit |
|---|---|---|
| Nuclear Medicine (including nuclear cardiology and PET scans) |
|
|
| Endovenous laser treatment | Physician and facility must be accredited for vein center by the Intersocietal Accreditation Commission |
If you perform interpretation services for additional services beyond what your specialty is privileged for, your claims will be denied. You must submit an appeal for further consideration.
- Use the Diagnostic Imaging Professional Privileging Application to specifically request the privilege to be reimbursed for additional CPT codes beyond your specialty.
- Be sure to include documentation of your education, additional training, and volume of studies.
- Certain diagnostic imaging services performed in a hospital setting may require submission of a letter from the chief of radiology attesting to the hospital privileges of the individual provider involved in the appeal. The letter should also include recognition of the provider's appropriate course of training for the interpretation of the procedure.
- X-ray and fluoroscopy require a documented review and report by a qualified radiation physicist that encompasses standards for safe operation of equipment, policies, and procedures required for appropriate quality assessment and quality assurance. Documentation requirements follow standards developed by the American College of Radiology (www.acr.org).
- To request a privileging exception, fill out and send the Privileging Exception Request Form.
For privileging application questions, call Network Management & Credentialing Services at 1-800-316-BLUE (2583).
