CurrentHealth-New-EnglandPolicy N/A

Prior Authorization for Outpatient Advanced Diagnostic Imaging, Sleep Studies, and Genetic Testing

This policy governs prior authorization requirements and utilization management for outpatient advanced diagnostic imaging (CT, MRI/MRA, PET, nuclear cardiology), sleep studies, and genetic lab testing for Health-New-England products. It affects ordering physicians and facilities rendering outpatient services.

Policy Summary

PayerHealth-New-England

PolicyPrior Authorization for Outpatient Advanced Diagnostic Imaging, Sleep Studies, and Genetic Testing

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization from eviCore (web portal 24/7 or phone during call center hours) before performing outpatient advanced diagnostic imaging or listed services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior auth requiredservice-level requirement

6 listedprocedure categories

Mon-Fri 8am-9pm ESTcall center hours

Portal 24/7web access

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Coverage Criteria

Authorization and Accreditation Requirements

Covered when outpatient services meet prior authorization and facility accreditation requirements

Outpatient prior authorization and accreditation: Service is outpatient; prior authorization obtained from eviCore prior to rendering outpatient service; suppliers of the technical component for advanced diagnostic imaging (MRI, CT, PET) must be accredited per CMS requirements (hospitals excluded)

Order must include patient symptoms, past clinical history, and prior treatment information at the time of the prior authorization request; failure to obtain prior authorization may result in denial of payment; this policy does not apply to emergency room, observation, or inpatient imaging procedures.

This policy does not apply to imaging performed in the emergency room, observation, or inpatient settings. The requirements and prior authorization processes described here are limited to outpatient services only; inpatient and emergent care pathways follow separate authorization and coverage rules.

Advanced Diagnostic Imaging procedures, sleep studies, and genetic testing performed in the outpatient setting require prior authorization through eviCore healthcare. Failure to obtain prior authorization for the listed outpatient procedures may result in denial of payment. This policy applies to all Health‑New‑England products and applies when the facility and suppliers meet any applicable accreditation requirements for the technical component of advanced imaging.

Coding / Procedure Codes

Procedures That Require Prior AuthorizationmixedCovered

CT Scan	CT Scan
MRI/MRA	MRI/MRA
PET Scan	PET Scan
Nuclear Cardiology	Nuclear Cardiology
Sleep Studies	Sleep Studies
Genetic Lab Testing	Genetic Lab Testing

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient advanced diagnostic imaging, sleep studies, and genetic lab testing performed in an outpatient setting. eviCore healthcare performs utilization management for these services on behalf of Health-New-England. This requirement does not apply to emergency room, observation, or inpatient imaging procedures. Failure to obtain prior authorization for listed procedures may result in denial of payment.

Applies to all HNE products
Excludes emergency room, observation, and inpatient imaging

Note

Provider Actions — Authorization Responsibility

The ordering physician is responsible for obtaining prior authorization from eviCore healthcare for the requested service. The facility providing radiological services is responsible for ensuring authorization has been obtained prior to rendering service. Providing services without prior authorization may result in denial of payment.

Ordering physician must obtain prior authorization

Covered Indications and Settings

Prior authorization required for listed modalities when outpatient

Prior authorization is required when any of the following modalities are performed in the outpatient setting:

Modalities requiring prior auth: CT; MRI/MRA; PET; Nuclear Cardiology; Sleep Studies; Genetic Lab Testing

Prior authorization requests must be submitted to eviCore (web portal available 24/7 or by phone during call center hours).

Prior Authorization Summary

Prior Authorization

Prior authorization required for listed outpatient modalities

Advanced Diagnostic Imaging (CT, MRI/MRA, PET, Nuclear Cardiology), Sleep Studies, and Genetic Lab Testing require prior authorization when performed in an outpatient setting for all HNE products.

Procedures listed: CT Scan; MRI/MRA; PET Scan; Nuclear Cardiology; Sleep Studies; Genetic Lab Testing.
This prior authorization requirement does not apply to emergency room, observation, or inpatient imaging procedures.

Definitions

Advanced Diagnostic Imaging — Definitions and Key Attributes

Advanced Diagnostic Imaging (definition)CMS-defined advanced diagnostic imaging procedures include MRI, CT, and nuclear medicine imaging such as PET.

Prior authorization settingRequired when advanced diagnostic imaging services are performed in an outpatient setting.

Accreditation requirementSuppliers of the technical component (TC) of advanced diagnostic imaging services must be accredited per CMS; this applies to physicians, nonphysician practitioners, and independent testing facilities; hospitals are excluded.

Scope of accreditation ruleAccreditation requirement applies to the supplier furnishing the technical component only, not to the interpreting physician.

Applicability to productsPolicy and requirements apply to all Health-New-England (HNE) products.

Contrast and Technical-Supplier Rules

Billing Rule

Accreditation required for technical component suppliers of advanced imaging

Suppliers of the technical component (TC) of advanced diagnostic imaging services must be accredited per CMS requirements; this applies to physicians, nonphysician practitioners, and Independent Testing Facilities, but excludes hospitals.

Accreditation requirement follows CMS definitions for advanced diagnostic imaging (MRI, CT, PET).
Requirement applies to suppliers furnishing the technical component, not to physicians interpreting studies.

Background

This policy describes utilization management and prior authorization processes rather than clinical indications. It governs the administrative requirements for outpatient advanced diagnostic imaging, sleep studies, and genetic lab testing — including when prior authorization is required and potential payment denial for services rendered without authorization — and is applicable across all HNE products.