Read High-Tech Imaging Program Prior Authorization Code Matrix text version

High-Tech Imaging Program Prior Authorization Code Matrix

The matrix below contains all of the procedure codes NIA will authorize on behalf of Tufts Health Plan. This matrix shows the codes for those services subject to prior authorization by NIA. If a service is authorized with a code in column one (Authorized CPT Code) and billed with a code in the corresponding group in column three (Allowable Billed Groupings), the service is eligible for coverage, subject to the provisions of the member's benefit plan document. Services rendered as part of emergency room services or in the hospital inpatient setting are not subject to prior authorization. 1. Authorized CPT Procedure Code 70336 70450 70480 70486 70490 70496 70498 70540 70544 70547 70551 70551 70554 71250 71275 71550 71555 72125 72128 72131 72141 72146 72148 72159 72191 72192 72196 72198 73200 73206 73220 73221 73225 73700 73706 73720 73721

2. Description MRI Temporomandibular Joint CT Head/Brain CT Orbit CT Maxillofacial/Sinus CT Soft Tissue Neck CT Angiography, Head CT Angiography, Neck MRI Orbit, Face, and/or Neck MRA Head MRA Neck MRI Brain MRI Internal Auditory Canal Functional MRI Brain CT Chest CT Angiography, Chest (non coronary) MRI Chest MRA Chest (excluding myocardium) CT Cervical Spine CT Thoracic Spine CT Lumbar Spine MRI Cervical Spine MRI Thoracic Spine MRI Lumbar Spine MRA Spinal Canal CT Angiography, Pelvis CT Pelvis MRI Pelvis MRA Pelvis CT Upper Extremity CT Angiography, Upper Extremity MRI Upper Extremity, other than Joint MRI Upper Extremity Joint MRA Upper Extremity CT Lower Extremity CT Angiography, Lower Extremity MRI Lower Extremity, other than Joint MRI Lower Extremity Joint

3. Allowable Billed Groupings 70336 70450, 70460, 70470 70480, 70481, 70482 70486, 70487, 70488, 76380 70490, 70491, 70492 70496 70498 70540, 70542, 70543 70544, 70545, 70546 70547, 70548, 70549 70551, 70552, 70553 70551, 70552, 70553, 70540, 70542, 70543 70554, 70555 71250, 71260, 71270 71275 71550, 71551, 71552 71555 72125, 72126, 72127 72128, 72129, 72130 72131, 72132, 72133 72141, 72142, 72156 72146, 72147, 72157 72148, 72149, 72158 72159 72191 72192, 72193, 72194 72195, 72196, 72197 72198 73200, 73201, 73202 73206 73218, 73219, 73220 73221, 73222, 73223 73225 73700, 73701, 73702 73706 73718, 73719, 73720, 73721, 73722, 73723 73721, 73722, 73723, 73718, 73719, 73720

Originated 04/2006, Revised 01/2012 2108688

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Tufts Health Plan -- Prior Authorization Imaging Code Matrix

1. Authorized CPT Procedure Code 73721 73725 74150 74174* 74175 74176 74181 74185 74261** 74263** 75557 75572 75573 75574*** 75635 76380 76390 77058 77084 78451 78459 78472 78608 78813 78816 S8037

2. Description MRI Hip MRA Lower Extremity CT Abdomen CT Angiography, Abdomen and Pelvis CT Angiography, Abdomen CT Abdomen and Pelvis, Combination MRI Abdomen MRA Abdomen Diagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography) Screening CT Colonoscopy (Virtual Colonoscopy, CT Colonography) MRI Heart CT Heart CT Heart congenital studies, non-coronary arteries CT Coronary Angiography CT Angiography, Abdominal Arteries CT Limited or Follow-Up MRI Spectroscopy MRI Breast MRI Bone Marrow Myocardial Perfusion Imaging -- Nuclear Cardiology PET Scan, Heart MUGA Scan PET Scan, Brain PET Scan PET Scan with concurrently acquired CT for attenuation correction and anatomic, localization MR Cholangiopancreatography

3. Allowable Billed Groupings 72195, 72196, 72197, 73721, 73722, 73723 73725 74150, 74160, 74170 74174 74175 74176, 74177, 74178 74181, 74182, 74183, S8037 74185 74261, 74262 74263 75557, 75559, 75561, 75563, 75565 75572 75573 75574 75635 76380, 70486, 70487, 70488 76390 77058,77059 77084 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481, 78483, 78499 78459, 78491, 78492 78472, 78473, 78494, 78496 78608, 78609 78811, 78812, 78813, 78814, 78815, 78816 78811, 78812, 78813, 78814, 78815, 78816 S8037, 74181, 74182, 74183

*New code effective for dates of service on or after January 1, 2012 **Effective for dates of service on or after April 1, 2011 *** Effective for dates of service on or after July 1, 2011

Audit and Disclaimer Information

Tufts Health Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this Payment Policy. If such an audit determines that your office/facility did not comply with this payment policy, Tufts Health Plan will expect your office/facility to refund all payments related to non-compliance. This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is neither a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, and adherence to plan policies and procedures and claims editing logic.

Originated 04/2006, Revised 01/2012

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Tufts Health Plan -- Prior Authorization Imaging Code Matrix

This policy does not apply to Tufts Medicare Preferred HMO or Private Health Care Systems (PHCS) network also known as Multiplan members. This policy applies to CareLink for providers in the Massachusetts and Rhode Island service areas for pricing purposes only. Providers in the New Hampshire service area are subject to Cigna healthcare's provider arrangement for the purpose of CareLink members.

Originated 04/2006, Revised 01/2012

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Tufts Health Plan -- Prior Authorization Imaging Code Matrix

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High-Tech Imaging Program Prior Authorization Code Matrix

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High-Tech Imaging Program Prior Authorization Code Matrix