Radiology policies
***Carelon Musculoskeletal, Interventional Pain Management, Cardiology and Radiology
Effective for dates of service on and after Oct. 1, 2024, Prevea360 Health Plan has partnered with Carelon, a utilization management (UM) program vendor, to support the provider submission and medical necessity review process for select musculoskeletal (MSK), cardiology, and radiology services. Submissions and review by Carelon will replace those previously managed by NIA Magellan.
The following information applies to the NIA (Evolent) program, for dates of service on or prior to Sept. 30, 2024. Authorizations obtained through NIA (Evolent) will be available for viewing through 12/31/2024:
Providers can request prior authorization through the NIA website www.RadMD.com or by calling the NIA toll-free number, 1-877-642-0622.
Prior authorization is required for the following outpatient radiology procedures through NIA:
- CT scan
- Nuclear Exercise - Tolerance Test (ETT)
- MRI/MRA
- PET Scan
Radiology policies 2024 Coding Matrix - NIA (PDF)
Radiology policies 2023 Coding Matrix - NIA (PDF)
NIA advanced imaging guidelines (PDF)
Prevea360 Health Plan Provider FAQ (PDF)
Note: It is the responsibility of the ordering physician or clinic to obtain authorization. Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim. Imaging procedures performed during an emergency room and/or urgent care visit or in observation and inpatient facilities do not require authorization.