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NIA Magellan1 Frequently Asked Questions(FAQ’s)For Ambetter from CeltiCare Health ProvidersQuestionGENERALWhy is Ambetter fromCeltiCare Healthimplementing anoutpatient imagingprogram?AnswerTo improve quality and manage the utilization of nonemergent MR, CT, PET, CCTA, Nuclear Cardiology/MPI,Echocardiography and Stress Echo procedures for ourmembers.Why did Ambetterfrom CeltiCare Healthselect NIA Magellanto manage itsoutpatient advancedimaging services?An affiliate of Magellan Health Services, NIA Magellan wasselected to partner with us because of its clinically drivenprogram designed to effectively manage the quality, patientsafety and while ensuring appropriate utilization of resourcesfor Ambetter from CeltiCare Health membership.Which Ambetter fromCeltiCare Healthmembers will becovered under thisrelationship and whatnetworks will beused?Effective January 1, 2014, NIA Magellan began managingnon-emergent outpatient imaging services for Ambetter fromCeltiCare Health membership through Ambetter fromCeltiCare Health contractual relationships.PRIOR AUTHORIZATIONImplementation was January 1, 2014What is theimplementation datefor this outpatientimaging program?—1 NIA Magellan refers to National Imaging Associates, Inc.1 - NIA Magellan/Ambetter from CeltiCare Health Frequently Asked Questions

What imagingservices requireprovider’s to obtain aprior authorization?The following imaging procedures require prior authorizationthrough NIA Magellan: CT/CTA MRI/MRA PET CCTA Nuclear Cardiology/MPI Echocardiography Stress EchoEmergency room, observation and inpatient imagingprocedures do not require prior authorization from NIAMagellan. If an emergency clinical situation exists outside of ahospital emergency room, please contact NIA Magellanimmediately with the appropriate clinical information for anexpedited review.When is priorauthorizationrequired?Prior authorization is required for outpatient, non-emergentMR, CT, PET, CCTA, Nuclear Cardiology/MPI,Echocardiography and Stress Echo procedures. Orderingproviders must obtain prior-authorization of these proceduresprior to the service being performed at an imaging facility.Is prior authorizationnecessary forsedation with anMRI?No, prior authorization is not required for sedation whenperformed with an MRI.Is an NIA Magellanauthorization numberneeded for a CTguided biopsy?Can a chiropractororder images?Are routine radiologyservices a part of thisprogram?No, prior authorization is not required for this procedure.Are inpatientadvanced imagingprocedures includedin this program?YesNo. Routine radiology services such as x-ray, ultrasound ormammography are not part of this program and do not requirea prior authorization through NIA Magellan.No. Inpatient procedures are included in the authorization forthe inpatient stay that is managed through the Ambetter fromCeltiCare Health Medical Management Department.2- NIA Magellan/Ambetter from CeltiCare Health Frequently Asked Questions

Is prior authorizationrequired for imagingstudies performed inthe emergencyroom?How does theordering providerobtain a priorauthorization fromNIA Magellan for anoutpatient advancedimaging service?What information isrequired in order toreceive priorauthorization?No. Imaging studies performed in the emergency room arenot included in this program and do not require priorauthorization through NIA Magellan.Providers will be able to request prior authorization via theInternet (www.RadMD.com) or by calling NIA Magellan at 1877-687-1186.To expedite the process, please have the followinginformation ready before logging on to the Website or callingthe NIA Magellan call center staff (*denotes requiredinformation): Can a providerrequest more thanone procedure at atime for a member(i.e., CT of abdomenand CT of thorax)?Name and office phone number of ordering physician*Member name and ID number*Requested examination*Name of provider office or facility where the service will beperformed*Anticipated date of service (if known)Details justifying examination* Symptoms and their duration Physical exam findings Conservative treatment patient has alreadycompleted (e.g., physical therapy, chiropractic orosteopathic manipulation, hot pads, massage, icepacks, medications) Preliminary procedures already completed (e.g., xrays, CTs, lab work, ultrasound, scoped procedures,referrals to specialist, specialist evaluation) Reason the study is being requested (e.g., furtherevaluation, rule out a disorder) Yes. NIA Magellan can handle multiple authorizationrequests per contact. Separate authorization numbers areissued by NIA Magellan for each study that is authorized.3- NIA Magellan/Ambetter from CeltiCare Health Frequently Asked Questions

What kind ofresponse time canordering providersexpect for priorauthorization?The best way to increase the possibility of having anauthorization request approved on line throughwww.RadMD.com or at the time of the first call through thetoll-free number, 1-877-687-1186 is to have knowledge of thecase including: The patient’s history and diagnosis Reason for the study Findings on physical examination Results of previous imaging studies, and History of medical or surgical treatmentA determination will be made within two business days afterreceipt of request and clinical information (if necessary). Incertain cases, the review process can be extended ifadditional clinical information is required to make adetermination.The NIA Magellan authorization number consists of eight orWhat does the NIAnine alpha-numeric characters. In some cases, the orderingMagellanauthorization number provider may instead receive an NIA Magellan trackingnumber (not the same as an authorization number) if thelook like?provider’s authorization request is not approved at the time ofinitial contact. Providers can use either number to track thestatus of their request online or through an Interactive VoiceResponse (IVR) telephone system.You will receive a tracking number and NIA Magellan willIf requestingauthorization through contact you to complete the process.RADMD and therequest pends, whathappens next?No, those requests will need to be called into NIA Magellan’sCan RadMD be usedCall Center for processing. The number to call to obtain ato request anprior authorization is 1-877-687-1186.expeditedauthorizationrequest?If the radiologist or rendering provider feels that, in addition toWhat happens if athe study already authorized, an additional study is needed,patient is authorizedplease contact NIA Magellan immediately with the appropriatefor a CT of theclinical information for an expedited review. The number to callabdomen, and theto obtain a prior authorization is 1-877-687-1186.radiologist orrendering physicianfeels an additionalstudy of the thorax isneeded?4- NIA Magellan/Ambetter from CeltiCare Health Frequently Asked Questions

Can the renderingfacility obtainauthorization in theevent of an urgenttest?How long is the priorauthorization numbervalid?Yes, If an urgent clinical situation exists outside of a hospitalemergency room, please contact NIA Magellan immediatelywith the appropriate clinical information for an expeditedreview. The number to call to obtain a prior authorization is 1877-687-1186.The authorization number is valid for 30 days from the date ofdecision. When a procedure is authorized, NIA Magellan willuse the date of the decision as the starting point for the 30 dayperiod in which the examination must be completed.Is prior authorizationnecessary for anoutpatient, advancedimaging service ifAmbetter fromCeltiCare Health isNOT the member’sprimary insurance?If a provider obtains aprior authorizationnumber does thatguarantee payment?Yes.Does NIA Magellanallow retroauthorizations?Can a provider verifyan authorizationnumber online?Will the NIA Magellanauthorization numberbe displayed on theAmbetter fromCeltiCare HealthWebsite?SCHEDULING EXAMSHow will NIAMagellandetermine where toAn authorization number is not a guarantee of payment.Authorizations are based on medical necessity and arecontingent upon eligibility and benefits. Benefits may besubject to limitations and/or qualifications and will bedetermined when the claim is received for processing.It is important that rendering facility staff be educated on theprior authorization requirements. Beginning 1/1/2014, claimsfor MR, CT, PET, CCTA, Nuclear Cardiology/MPI,Echocardiography and Stress Echo that have not beenproperly authorized will not be reimbursed. The renderingfacility should not schedule procedures without priorauthorization.Yes. Providers can check the status of member authorizationquickly and easily by going to the Website atwww.RadMD.com.No.NIA Magellan will manage non-emergent outpatient radiologyservices through Ambetter from CeltiCare Health contractualrelationships.5- NIA Magellan/Ambetter from CeltiCare Health Frequently Asked Questions

schedule an exam foran Ambetter fromCeltiCare Healthmember?Why does NIAMagellan ask for adate of service whenauthorizing aprocedure? Dophysicians have toobtain anauthorization beforethey call to schedulean appointment?At the end of the authorization process, NIA Magellan askswhere the procedure is being performed and the anticipateddate of service. The exact date of service is not required.Physicians should obtain authorization before scheduling thepatientWHICH MEDICAL PROVIDERS ARE AFFECTED?Any provider who orders or performs advanced imagingWhich medicalprocedures in an outpatient setting. Ordering providers willproviders areneed to request a prior authorization and theaffected by thedelivering/servicing providers will need to be sure there is aoutpatient imagingprior authorization number in order to bill the service.program? CLAIMS RELATEDWhere do providerssend their claims foroutpatient, nonemergent advancedimaging services?How can providerscheck claims status?Who should aprovider contact ifthey want to appeal aprior authorization orOrdering providers, including Primary CareProviders (PCPs) and Specialty Care providers.Delivering/Servicing providers who performdiagnostic advanced imaging procedures at: Freestanding diagnostic facilities Hospital outpatient diagnostic facilities Provider officesProviders should send claims to the address indicated on theback of the Ambetter from CeltiCare Health member ID card.Providers are also encouraged to follow their normal EDIclaims process.Providers should check claims status at the Ambetter fromCeltiCare Health Website at www.celticarehealthplan.com.Providers are asked to please follow the appeal instructionsgiven on their non-authorization letter or Explanation ofPayment (EOP) notification.6- NIA Magellan/Ambetter from CeltiCare Health Frequently Asked Questions