Radiology

Radiology Utilization and Quality Management Program

The Radiology Utilization and Quality Management Program is designed to evaluate the appropriate utilization of high technology diagnostic imaging services.

The preauthorization service is provided by American Imaging Management (AIM). Wellmark has selected AIM as a preferred vendor, to process diagnostic imaging preauthorization requests for Wellmark Blue Cross and Blue Shield plans.

The following sections will help you get started with this program:

• Services/Procedures Provided
• Who Requires Preauthorization
• Information Needed to Request Preauthorization
• Request and Check Preauthorization
• Radiology Pre-Service Appeal Process/Post-Service Provider Inquiry Process
• Provider Tools

Services/Procedures Provided

These non-emergency outpatient diagnostic imaging services performed in a freestanding imaging center, hospital outpatient setting, or in-office via physician-owned high-tech equipment require preauthorization:

• Computed Tomography (CT) scans
• Computed Tomographic Angiography (CTA) scans
• Nuclear Cardiology (For example: SPECT scans, cardiolyte stress tests)
• Positron Emission Tomography (PET)
• Magnetic Resonance Imaging (MRI)
• Magnetic Resonance Angiography (MRA)
• Echocardiography (stress, resting transthoracic, transesophageal)*

*Beginning with services provided on and after November 1, 2008, Wellmark requires notification for additional outpatient cardiac services. Newly added services will have a two-phase implementation process:

• November 1 – April 30, 2009: Notification and requested clinical information is required; however, benefits for the service will be approved. Servicing providers’ claims will deny when a notification with clinical information is not provided before the service is performed.
• Effective May 1, 2009: Notification and requested clinical information is required and preauthorization will be performed, resulting in the approval or denial of benefits for the requested services. Servicing providers’ claims will process based on the approval or denial.

Learn about CPT codes that require preauthorization.

Wellmark provides benefits for related outpatient diagnostic imaging services that share clinical indications with the specific services approved on the preauthorization. This change broadens the scope of the preauthorization and affects the following diagnostic imaging services:

• CT chest and CTA chest
• MRI upper extremity joint and MRI upper extremity non-joint
• MRI lower extremity and MRI pelvis

Note:

• Ordering providers — should complete the preauthorization process before scheduling the procedure.
• Delivering providers — should ask for the preauthorization number before scheduling and delivering the procedure.
• Preauthorization numbers are valid for sixty (60) days from the date issued. If 60 days have passed and the test has not been completed, a new preauthorization number is needed.

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Who Requires Preauthorization

The program applies to all of your patients who have coverage through:

• Wellmark Blue Cross and Blue Shield of Iowa
• Wellmark Health Plan of Iowa, Inc.
• Wellmark Blue Cross and Blue Shield of South Dakota

If a patient is covered by two Wellmark plans, preauthorization is required for the primary health plan. If a patient has another health plan other than a Wellmark plan as primary and the Wellmark plan is secondary, preauthorization is required. As of May 2007, Wellmark does not require preauthorization for patients whose primary coverage is with Medicare.

The preauthorization requirement does not apply to your patients covered by:

• Federal Employee Program (FEP)
• SelectFirst^®
• Medicare – primary payer

Most Blue Cross and Blue Shield Plans do not require outpatient diagnostic imaging preauthorization for members receiving out-of-area services. However, the Plans below require diagnostic imaging preauthorization for their members who receive out-of-area (BlueCard^®) services. This list will be updated as Plans implement similar out-of-area requirements. Although the member is responsible for payment reductions if the preauthorization is not performed, only ordering providers can request the preauthorization.

• North Carolina
• Tennessee

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Information Needed To Request Preauthorization

The following information is needed for every preauthorization request (please have the patient's chart or office notes available to expedite the process):

• Insurance information (member's ID number, group number, etc.)
• Patient's name and date of birth
• Ordering provider's name, address and telephone number
• Type of service and/or CPT code (if available)
• Patient's symptoms, reason (indication) for the imaging procedure and/or ICD-9 CM diagnosis code
• Results of pertinent previous studies (labs, x-rays, etc.) and treatments, including their duration

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Request and Check Preauthorizations

The following table provides you with the different tools to use and How To instructions when utilizing this program:

Requesting Preauthorizations	Instructions
Web	Submit preauthorization requests online 24 hours a day, seven days a week. Real time responses will be given, if the request meets all criteria. This is the most efficient method for requesting a preauthorization(s). Manage Radiology Preauthorizations How to request a preauthorization using the Web
Phone	AIM's call center is open Monday through Friday from 7:30 AM to 6 PM (Central Time) Call center phone number — 1-888-800-4497
Fax	Complete the preauthorization fax form and fax the completed form to AIM — 1-800-610-0050. Radiology Fax Form Oncology Fax Form Note: This is the most inefficient method to request preauthorization.
Checking Preauthorizations	Instructions
Web	Check preauthorization inquiries online 24 hours a day, seven days a week. This is the most efficient method to inquire if a preauthorization is in place. Manage Radiology Preauthorizations How to check a preauthorization using the Web
Phone	AIM's call center is open Monday through Friday from 7:30 AM to 6 PM (Central Time) Call center phone number — 1-888-800-4497

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Radiology Pre-Service Appeal Process/Post-Service Provider Inquiry Process

Pre-Service Appeals

Contact AIM within 180 days of receiving the denial letter by:

Post-Service Inquiries

Print this process section

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Provider Tools

The following tools will assist you in the preauthorization process:

Request or Check Preauthorizations

• Manage Radiology Preauthorizations

Fact Sheets and Guides

• Diagnostic Clinical Guidelines (AIM Web site)
• Outpatient Diagnostic Imaging Reference List – Iowa (PDF)
• Outpatient Diagnostic Imaging Reference List – South Dakota (PDF)

Forms

• Radiology Fax Form
• Oncology Fax Form

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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.