QUEST Integration - Physician Responsibility for Obtaining Precertification of Imaging Studies

Original Effective Date:

10/01/2006

Current Effective Date:

01/01/2015

1. Effective January 1, 2009, all advanced imaging studies require precertification through National Imaging Associates, Inc. (NIA). (Note: The information on this page only applies to precertification of advance imaging studies. For precertification information for other medical services, refer to the QUEST Integration - Benefit Information , QUEST Integration - Precertification - Medical, and QUEST Integration - Precertification Timeliness Standards sections of the Provider Handbook.) The term precertification is the same as prior authorization.
   1. Precertification is required for all outpatient advanced imaging scans.
   2. Selected physicians have been waived from precertification requirements for MRI, MRA, CT, CTA and nuclear cardiology services.
   3. All ordering physicians are required to precertify functional MRI, PET, CCTA (ordered by cardiologists only) and CT colonography scans.
   4. Precertification is not required for advanced imaging services when performed in the emergency department or observation room or for services performed on an inpatient basis.
2. The ordering physician is responsible for obtaining precertification. Physicians may call NIA toll free at 1 (866) 306-9729, from 6 a.m. to 6 p.m., weekdays, Hawaii Standard Time.
   1. NIA's call center is closed on Saturdays, Sundays and federal holidays.
   2. If a planned study is to be performed after hours or on weekends or holidays, the ordering physician should contact NIA in advance to obtain precertification.
   3. If a study is provided on an urgent basis and the physician is unable to obtain precertification prior to the study being performed, the physician should contact NIA on the following business day to obtain precertification.
3. The NIA Call Center is staffed with experienced Call Center representatives, nurses, board-certified radiologists and physicians from other specialties.
   1. NIA will request information about the patient's symptoms, past clinical history and prior treatment, and the physician should have this information available at the time of the call.
   2. Evidence-based clinical guidelines and algorithms that have been modified to meet HMSA's needs are used to expedite the review, and immediate precertification can be given by NIA staff about 60 percent of the time.
   3. If clinical input is required, the case will be referred to clinical staff for review. In these cases a determination can generally be made within two working days, assuming all pertinent clinical information is available.
   4. The average call takes less than five minutes to complete.
4. A precertification number from NIA does not guarantee HMSA payment. Payment is subject to plan benefits and deductibles, any applicable waiting periods and member eligibility at the time of service.
5. Clinical guidelines that have been adapted to meet HMSA's needs are available for reference (see www.radmd.com).

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