Independent Radiology Services (Chapter 34)
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Standards, participation requirements, billing/claims rules, prior authorization, and recipient billing rules for independent radiology facilities serving Alabama Medicaid beneficiaries.
No material clinical or coverage changes in this revision.
Covered services and participation requirements
Covered Services and Participation Requirements
Services covered when provided under the specified conditions:
ALL of the following
- Services must be medically necessary.
- The patient must be eligible for Medicaid at the time the services are rendered.
- Services must be ordered and provided by or under the direction of a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by state law.
- Services must be provided in an office or similar facility other than a hospital outpatient department or clinic.
- Services must be provided by a radiology facility that meets the requirements for participation in Medicare.
- Radiology services are restricted to procedures described in the CPT manual (70010-79999) or locally assigned HCPCS codes used only by Medicaid to supplement the CPT listing.
Participation requirements (facility must meet ALL):
- Be certified for participation with Medicare.
- Be independent of any hospital, clinic, or physician's office.
- Be licensed in the state where located, when state licensure is required.
- Submit to routine audits by Medicaid.
- Complete an application with all required attachments.
- Sign a provider agreement.
- Sign a Direct Deposit Authorization.
- Sign a Civil Rights Statement of Compliance.
- Effective date of enrollment is the date of Medicare certification, except providers requesting enrollment more than 120 days after certification will be enrolled on the first day of the month the request is received.
Codes and coding notes
| 70010-79999 | CPT radiology procedure codes range defining services covered |
Prior authorization and provider procedures
Prior Authorization required; urgent and post-service request windows
Prior authorization is required for certain radiology codes. The performing provider (facility) or the referring/ordering provider may request prior authorization; requests must be made prior to the test being performed. In urgent situations where prior authorization cannot be obtained before the test, a PA may be requested within 14 days from the date of service and the case must meet the 'urgent' criteria to be considered. Providers have 30 days from the date of service to submit a request to change or add a code to an approved case. If a request is denied, written notice explaining the reason and the recipient's and provider's appeal rights will be sent.
- PA must be requested prior to the test; performing or referring/ordering provider may request PA.
- Urgent cases: PA may be requested within 14 days of service and must meet 'urgent' criteria.
- Providers may request code changes/additions to an approved case within 30 days of service.
- Denials: written notice to provider and recipient with reason and appeal information.
Defined terms
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