Musculoskeletal (MSK) Surgery Prior Authorization Program
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Defines prior authorization requirements for non-emergent outpatient and inpatient hip, knee, shoulder, lumbar and cervical surgeries for Ambetter of Alabama members and informs participating providers about NIA-managed authorization processes.
Prior authorization for specified non-emergent inpatient and outpatient MSK surgeries will be managed by National Imaging Associates (NIA) effective March 1, 2024.
NIA will manage inpatient and outpatient MSK surgeries while Ambetter of Alabama remains responsible for claims adjudication and medical policies.
Coverage Criteria for MSK Surgeries
MSK Surgeries Requiring Prior Authorization
Prior authorization is required for the following non-emergent MSK surgeries when scheduled for Ambetter of Alabama members:
Providers may begin contacting NIA on March 1, 2024 for procedures scheduled on or after that date. Emergency MSK surgery cases admitted through the emergency room are excluded from NIA management.
Emergency MSK surgery cases that are admitted through the emergency department are excluded from NIA management. In addition, any MSK surgery procedures not included in the listed procedure types are not managed by NIA.
This document announces that prior authorization for specified non-emergent MSK surgeries will be managed by National Imaging Associates (NIA) beginning March 1, 2024. It lists the procedure categories subject to NIA prior authorization (hip, knee, shoulder, lumbar and cervical surgeries) but does not set out specific medical necessity criteria in this notice.
Coding / Procedure Identifiers
| Revision/Conversion Hip Arthroplasty | Revision/Conversion Hip Arthroplasty |
| Total Hip Arthroplasty/Resurfacing | Total Hip Arthroplasty/Resurfacing |
| Femoroacetabular Impingement (FAI) Hip Surgery | Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincer & labral repair) |
| Hip Surgery - Other | Hip Surgery -Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee) |
| Revision Knee Arthroplasty | Revision Knee Arthroplasty |
| Total Knee Arthroplasty (TKA) | Total Knee Arthroplasty (TKA) |
| Partial-Unicompartmental Knee Arthroplasty (UKA) | Partial-Unicompartmental Knee Arthroplasty (UKA) |
| Knee Manipulation under Anesthesia (MUA) | Knee Manipulation under Anesthesia (MUA) |
| Knee Ligament Reconstruction/Repair | Knee Ligament Reconstruction/Repair |
| Knee Meniscectomy/Meniscal Repair/Meniscal Transplant | Knee Meniscectomy/Meniscal Repair/Meniscal Transplant |
Provider Actions and Requirements
NIA prior authorization required
Prior authorization through National Imaging Associates (NIA) is required for specified non-emergent inpatient and outpatient hip, knee, shoulder, lumbar, and cervical surgeries for Ambetter of Alabama members beginning March 1, 2024; providers may contact NIA on or after March 1, 2024 to seek prior authorization for procedures scheduled on or after that date.
Provider notification and program roles
Providers may begin contacting NIA on March 1, 2024 to seek prior authorization for procedures scheduled on or after that date. Ambetter will continue to oversee the MSK program and remain responsible for claims adjudication and medical policies; NIA will manage the inpatient and outpatient MSK prior authorization process.
- Implementation planned for March 1, 2024 — contact NIA on or after this date for authorizations.
- Ambetter retains claims and medical policy responsibility while NIA manages prior authorization.
Authorization responsibility and facility verification
The ordering physician is responsible for obtaining prior authorization with NIA prior to performing the listed MSK surgeries; facilities should verify that an NIA prior authorization has been obtained prior to scheduling the surgery/procedure.
- Ordering physician must obtain prior authorization from NIA before the procedure.
- Facilities do not need a separate admission authorization but must ensure NIA authorization is in place before scheduling.
Risk if authorization not obtained
Failure of the ordering physician to obtain prior authorization from NIA for the listed MSK surgeries may result in lack of an approved authorization prior to scheduling; facilities should ensure authorizations are secured to avoid payment or scheduling issues.
- NIA does not manage emergency MSK cases admitted through the ED — those are excluded from this prior authorization process.
Background
Ambetter of Alabama implemented an MSK management program to promote clinically appropriate care and manage utilization for non-emergent musculoskeletal surgeries. Under the agreement, Ambetter retains responsibility for claims adjudication and medical policies while NIA will manage prior authorization for the listed inpatient and outpatient hip, knee, shoulder, lumbar and cervical procedures.
Definitions
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