CurrentColorado Rocky Mountain Health PlansPolicy RADIOLOGY 013B.62

Oxford's Outpatient Imaging Self-Referral Policy – Oxford Administrative Policy

Defines which outpatient imaging procedures performed in physician office settings are payable by Oxford, applicable provider specialties for specific CPT codes, accreditation requirements, and prior authorization process through eviCore. Excludes inpatient, ambulatory surgery, emergency, and pre-operative testing imaging.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOxford's Outpatient Imaging Self-Referral Policy – Oxford Administrative Policy

Policy CodePolicy RADIOLOGY 013B.62

Change TypeRevisions & removals (codes/cross‑references) + administrative reclassification

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization from eviCore for diagnostic radiology or diagnostic cardiology procedures that require it; authorizations are valid 45 calendar days for one date of service.

SourceLink

POLICY UPDATE CHANGES

Removed prior authorization limit for obstetrical ultrasounds beyond three per member per pregnancy (01/01/2026).

Clarified CPT applicability for Pediatric Cardiologists and removed instruction to refer to Obstetrical Ultrasonography policy for fetal CPT codes (01/01/2026).

Revised Nuclear Medicine section to remove instruction to refer to Cardiology Procedures for eviCore arrangement (01/01/2026).

Narrowed CPT code listings for Infertility Specialists/related specialties by removing CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814 (01/01/2026).

Removed instruction to refer to Obstetrical Ultrasonography clinical policy for CPT codes 76801-76828 in multiple specialty sections (01/01/2026).

Changed policy type from 'Clinical Policy' to 'Administrative Policy' (01/01/2026).

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45Authorization valid (calendar days)

CURRENTPolicy status

manyPolicy code count

Policy summary

Background: The Outpatient Imaging Self-Referral Policy is designed to promote appropriate use of diagnostic imaging in physician office settings by limiting payable outpatient imaging to procedures within a provider's specialty practice areas and by requiring accreditation from recognized organizations (eg, ACR, AIUM, IAC, RadSite, TJC). Oxford expects providers to be board-certified in the appropriate specialty and has engaged eviCore healthcare to manage prior authorization and accreditation submissions; accreditations should be submitted directly to eviCore's website for network/provider validation.

Scope: This administrative policy (Policy Number: RADIOLOGY 013B.62, effective January 1, 2026, last reviewed January 1, 2026) defines which outpatient imaging procedures performed in primary care or specialty physician offices are payable by Oxford (subject to member benefits), the applicable provider specialties mapped to CPT codes, required accreditations for specified imaging types, and the prior authorization process through eviCore. The policy excludes imaging performed during inpatient stays, ambulatory surgery, emergency room visits, and pre-operative/pre-admission testing.

Key metadata

Policy numberRADIOLOGY 013B.62

Document typeAdministrative

Effective date2026-01-01

Last review2026-01-01

Has material changetrue

Coverage stanceinformational

Scope summaryDefines payable outpatient imaging in physician office settings by specialty, accreditation requirements, and prior authorization via eviCore; excludes inpatient, ambulatory surgery, ER, and pre-op testing.

Authorization valid (calendar days)45

Applicability and general rules

Accreditation, certification, and exclusions

Accreditation Requirements

Providers performing certain imaging types must meet ONE of the listed accreditation standards:

Accepted accreditations

ACR: American College of Radiology (ACR)
AIUM: American Institute of Ultrasound in Medicine (AIUM)
IAC: Intersocietal Accreditation Commission (IAC)
RadSite

Applicable CPT codes by specialty (representative groups)

Policy-wide applicable CPT codes by specialty (representative)CPT

74018	Abdomen imaging (various specialties listed)
74019	Abdomen imaging
74021	Abdomen imaging
77080	DEXA studies, bone densitometry
77081	DEXA studies, bone densitometry
77085	DEXA studies, bone densitometry
71045	Chest imaging
71046	Chest imaging
71047	Chest imaging
71048	Chest imaging

1–10 of 117

1/12

Specialty applicability: Specialty-specific applicability and CPT mappings vary across the policy and some CPT codes were narrowed or removed in the current revision (see Revision History for details).

Action: Confirm specialty mapping and whether a procedure requires prior authorization with eviCore (prior authorization available via the Prior Authorization and Notification App or by phone at 1-877-Pre-Auth (773-2884)); authorizations are standard and valid for 45 calendar days for one date of service when required.

Definitions

Outpatient Imaging Self-Referral PolicyPolicy designating which imaging procedures are payable when performed in physician office settings by providers within their specialty practice and meeting accreditation requirements.

Authorization numberStandard authorization issued by eviCore, valid for 45 calendar days for a single advanced outpatient imaging procedure and one date of service.

Document changes and materiality

01/01/2026administrative (non-material)

Template update: policy type changed from 'Clinical Policy' to 'Administrative Policy'.

01/01/2026material (policy wording change)

Removed prior authorization language that previously required authorization for obstetrical ultrasound procedures beyond three per member per pregnancy.

01/01/2026material (code list clarification)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOxford's Outpatient Imaging Self-Referral Policy – Oxford Administrative Policy

Policy CodePolicy RADIOLOGY 013B.62

Change TypeRevisions & removals (codes/cross‑references) + administrative reclassification

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization from eviCore for diagnostic radiology or diagnostic cardiology procedures that require it; authorizations are valid 45 calendar days for one date of service.

SourceLink

On This Page

TJC: The Joint Commission (TJC)

Prior Authorization

Obtain prior authorization from eviCore when required

Providers must obtain prior authorization for diagnostic radiology or diagnostic cardiology procedures that require it through eviCore. Prior authorization may be requested via the eviCore Prior Authorization and Notification App or by phone at 1-877-Pre-Auth (773-2884). A standard authorization number is specific to the advanced outpatient imaging procedure requested and is valid for 45 calendar days for one date of service.

eviCore web Prior Authorization and Notification App
Phone: 1-877-Pre-Auth (773-2884)
Authorization valid 45 calendar days for one date of service

Documentation Required

Meet accreditation/certification requirements

Providers performing certain imaging (for example, breast ultrasound, echocardiography, and nuclear medicine) must meet one of the listed national accreditation standards and submit accreditations to eviCore for network/provider validation. Accepted accrediting organizations include the American College of Radiology (ACR), the American Institute of Ultrasound in Medicine (AIUM), the Intersocietal Accreditation Commission (IAC), RadSite, and The Joint Commission (TJC). Oxford has engaged eviCore to manage accreditation submissions; accreditations should be submitted directly to the eviCore healthcare website.

American College of Radiology (ACR)
American Institute of Ultrasound in Medicine (AIUM)
Intersocietal Accreditation Commission (IAC)
RadSite
The Joint Commission (TJC)

Billing Rule

Office vs inpatient/ER exclusions

This outpatient self-referral policy does not apply to imaging performed during inpatient stays, ambulatory surgery, emergency room visits, or pre-operative/pre-admission testing. Imaging performed in those settings is excluded from the office-based outpatient imaging rules in this policy.

Documentation Required

Confirm member benefit plan and mandates

Before relying on this policy, providers must confirm the member-specific benefit plan and any applicable federal or state mandates, because the member-specific benefit plan governs if there is a conflict. Check the member-specific benefit plan document and applicable mandates prior to using this policy.

Revised Pediatric Cardiologists CPT listing: clarified applicability of fetal echocardiography codes and removed instruction to refer to Obstetrical Ultrasonography policy for CPT 76820-76828.

01/01/2026non-material (cross-reference removal)

Nuclear Medicine section revised to remove instruction to refer to the Cardiology Procedures for eviCore arrangement clinical policy.

01/01/2026material (code removal/narrowing)

Narrowed Infertility Clinic/related specialties CPT list by removing specific obstetrical ultrasound codes (76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814).

01/01/2026material (cross-reference removal)Latest

Removed multiple cross-references to the Obstetrical Ultrasonography clinical policy for CPT codes 76801-76828 across several specialty sections.