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Aetna

All AETNA referrals should have code 99499 for every study.

All MRI
Needs authorization through MedSolution.

MRA, PET, CT, NUC MED
Needs authorization through AETNA directly.

MAMMOGRAMS
Under 40 needs referral.
Over 40 needs script for yearly.
Diagnostic and ultrasound need a referral.
OPEN CHOICE, MGD CARE, ELECT CHOICE & PPO – NO REFERRAL NEEDED FOR ANY STUDY.

ULTRASOUND
OB Sonograms no longer req referral.
All non-OB ultrasounds need a referral.

DEXA SCAN
No longer needs a precertification. (Updated on this site 1/25/2012)

ALL HMO PLANS NEED REFERRALS.

ALL OTHER PLANS WILL PAY MORE IF REFERRAL IS PRESENTED.

Aetna Better Health

MRI, MRA, PET, CT SCANS
No precertifiaction at Pinnacle Health locations required

Amerihealth Admin

MRI/CT/PET/BONE DENSITY/NUC MED
Needs authorization & letter of medical necessity.
Call phone # on card to see if precert is needed. All plans are different.

Amerihealth Mercy

PET, MRI, MRA, CT, NUC MED CARDIOG, CT GUIDED BIOPSY MAMMOGRAM
Needs precertification through Med Solutions as of October 1st, 2011.

MAMMOGRAMS
Screening mammogram – no age limit. 1 per year ok.
Diagnostic mammogram – ultrasound and biopsy need script.

Blue Cross POS

MAMMOGRAM
Screening & self referred under 40 not covered, but is OK with script.
Over 40 includes 1 per year including implants. Verbal script OK.

MAMMOGRAM/US
Under 40 needs script.

DEXA Scan
Needs script.

PET, SPEC IMAGING & BREAST MRI ONLY
Need authorization through Capital Blue Cross. (updated on this site 1/25/2012)

MRI, MRA, CT, NUC MED
Need authorization through NIA or the healthplan. (updated on this site 1/25/2012)

Keystone HMO & POS (CBC)

MRI, CT PET, MRA
Needs authorization through NIA.

POINT OF SERVICE
Needs a referral for biopsies.

NUC MED SPECT IMAGING
Needs authoriaztion through NIA.

SIALOGRAMS/ARTHROGRAMS
Needs a referral, not an auth because it is considered an outpatient surgery.

MAMMOGRAM & DEXA
No referral needed.

Highmark & Premiere Blue

MAMMOGRAM
Diagnostic mammogram needs script.

CTA CORONARY/HEART (76495) CTA CHEST (71275)
Precertification needed.

CTA CORONARY ARTERY (0148t)
Needs authorization through NIA.

CT, MRI, PET
Needs authorization through NIA.

DEXA – Needs script. (Premiere Blue ONLY)   Over 65 is covered as routine every 2 years.  Under 65 is covered as long as medical criteria is met per the medical policy.  No prior authorization is required.

ALL PREMIERE PRODUCTS
Need authorization through NIA.

Highmark Freedom Blue

MRI,MRA,CT,PET
Needs authorization through NIA.

Cigna

MRI,MRA,CT,PET,NUC MED,MUGA
Needs precert through MedSolutions.
File all paperwork through MedSolutions. (except for Shamokin Hospital)

BREAST BIOPSY
Do not need a precertification.

ULTRASOUND
One pregnancy ultrasound is OK, but all others need medical necessity proven to be paid.

Cigna through Health Partners

FOLLOW GUIDELINES ON CARD FOR AUTHORIZATONS

Gateway

CT,MRI,MRA
Need precertification through NIA.

ULTRASOUND
Prenatal US needs script only.
All other US need referral.
Anything done outside OB/GYN need referral.

BONE DENSITY
No authorization needed, script only. (effective January 1st, 2011)

MUGA SCAN
Need authorization.

MAMMOGRAM
Need script.
Breast biopsy needs referral unless OB/GYN is ordering.

ALL OTHER ULTRASOUND
Need referral when ordered by PCP or OB/GYN

DIAGNOSTIC XRAY
Most xrays do not need referral.
Referrals good from 90 days of issue date.

NUCLEAR MED
Need referral.

Geha

CT,MRI,MRA,PET
Call MedSolutions for precertification.
1-866-879-8317

Geisinger

CT,MRI,MRA,PET,NUC MED,CTA ECHOCARDIOGRAM
Each procedure has to have its own Auth# through NIA.

NUCLEAR CARDIOLOGY
All precerts go through NIA.
1-866-305-9729.
All plans included.

MAMMOGRAM,DEXA,BIOPSY
No referral needed.

Great West

MRI,CT,PET
Need to be authorized through MedSolutions.
File all claims, including xrays, to Great West/MedSolutions.

Health Partners

ALL STUDIES
Every study needs an authorization.
Call 215-967-4690
We are not in the network and cannot be at this moment.

Humana

CT,MRI,MRA,PET
Need authorization for HMO products.
Need notification for PFFS products.

Health America/Health Assurance

CT,MRI,MRA,PET, MRI ARTHROGRAM
Need authorization through NIA.

NEEDLE GUIDED BIOPSY (77021)
Need authorization through healthplan.

Advantra

BREAST MRI
Needs authorization, but proc 77021, needle guided biopsy, does NOT need auth.

Advantra One

DEXA
Nothing is required for bone density testing.

MAMMOGRAM
Under 40 needs script.

OB/GYN US
If ordered by OB, need script, no referral.
Confirmed preg needs no referral or auth.

If ordered by PCP, needs script & referral.
Confirmed pregnancy needs referral and/or auth.

MUGA SCAN (78472)
Need authorization through NIA.

PROC 76881 ONLY
Contact the healthplan provider.

ALL OTHER US
No longer need referrals (updated on site 1/25/2012)

One Call

We will only provide services and exams for the procedure codes listed on the provider authorization form/script that the patient brings with them to our office.

Mailhandlers

MRI/MRA/CT/PET/CTA/NUC MED
Need prior authorization through healthplan as of January 1st, 2011.

Sterling Option 1

No referral or precertification required.

Teamster’s / Today’s Options

No referral or precertification required.
carecorenational.com
1-866-422-5009

Tricare

MRI,MRA,CT
Effective July 15th, 2011 – check authorization through website:
www.hnfs.com

No authorization needed for advanced imaging.

Tricare Prime

OB ULTRASOUNDS
Need authorization

Everthing else needs nothing.

Medical Assistance

PET,MRI,MRA,CT, SPECT SCANS
Needs precertification.
Call 1-800-424-4213 (effective Sept 1, 2008)

Visit https://promise.dpw.state.pa.us

PPHN

CT/MRI/MRA/PET
Need authorization through NIA.

UPMC & UPMC For You

All Studies
All plans require a script.

 

United Healthcare

All Unison products became United Healthcare products on 1/1/2011.

CT, MRI, PET
Needs notification number for each study.

MRI, MRA,PET
Need authorization through healthplan.

CT, MEDICARE PRODUCTS
Need authorization through United Healthcare.

Veteran’s Choice

All Imaging requires authorization

 

Medicare

DEXA SCAN
Needs script.

MAMMOGRAM
Needs script.

 

Blue Cross – Ble Journey (previously Senior Blue) HMO/PPO

MAMMOGRAM & DEXA
No referral needed.

Dexa- Over 65 is covered as routine every 2 years.  Under 65 is covered as long as medical criteria is met per the medical policy.  No prior authorization is required.

BIOPSY, SIALOGRAMS & ARTHROGRAMS
Need referrals.

MRI, CT PET, MRA
Needs authorization through NIA.

SPEC IMAGING & NUC MED
Needs authorization through healthplan.

—–SENIOR BLUE PPO—–
MAMMOGRAM
No referral needed.
PET, MRI, MRA & CT
Need authorization through NIA.

 

Assurant Health

MAMMOGRAM
Under 40 years of age and diagnostic mammo need script.

Chiropractors Only

A special note to chiropractors ~

Unfortunately, due to insurance restrictions, diagnostic tests of any kind can not be ordered for Medicare patients. They must go through their Primary Care Physician. We apologize for the inconvenience this may cause you.