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Blue Cross Imaging Program Underway
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Type 1 Modalities
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Type 2 Modalities
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•CT/CTA/SPECT
•MRI/MRA
(except Breast MRI)
•Nuclear Cardiac Studies
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•Breast MRI
•PET Scans
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As of December 1, 2005, Blue Cross Blue Shield of
Massachusetts (BCBSMA) implemented new requirements for ordering
outpatient high-technology radiology services, including CT/CTA,
MRI/MRA, nuclear cardiac studies, SPECT, breast MRI, and PET scans.
However, based on MMS and other provider input, Blue Cross will not
begin denying claims for failure to pre-certify these services until
April 1, 2006. The requirements for ordering outpatient high-technology
imaging studies will exclude services provided in an emergency
department.
BCBSMA selected American Imaging Management (AIM)
to administer this program, which includes internet-based tools for
completing the requirements.
Customized
Approach
Based on provider input, the program will be customized based on imaging
modality (see table above) and utilization relative to the primary care
physician’s referral circle (see table, below).
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If the patient’s PCP falls in a group
with:
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Then prior to the patient receiving the test,
the ordering physician will need to complete:
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Lower-Than-Average Utilization
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• A registration process for Type 1
modalities (no clinical information required)
• A clinical review process for Type 2 modalities (submit clinical
information and, potentially, consult with a physician reviewer)
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| Higher-Than-Average Utilization |
A clinical review process for both Type
1 and Type 2 modalities (submit clinical information and, potentially,
consult with a physician reviewer)
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| A BCBSMA-Approved Radiology Management Program
or Certain Risk-Based Contracts |
Neither registration nor review is required.
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Blue Cross emphasized that completion of these
requirements and, where applicable, receipt of a pre-certification
number, are conditions of payment. The insurer is also requiring that
physicians contact AIM to request individual consideration for tests
that do not meet BCBSMA medical policies.
Physicians may use their existing online
services -- such as Emdeon Office, InfoDial, or a POS
device -- to determine each patient’s pre-certification
requirement.
Contact BCBSMA at (800) 316-BLUE (2583) for more
information regarding this initiative, including how to use provider
technologies to check process requirements for your patients. To contact
AIM directly, call (866) 745-1783 or log on to www.americanimaging.net.
– Dana Cooper
| BCBS, high-technology radiology services, imaging claims |
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