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State Authorization Requirements and Clinical Criteria

ARKANSAS AUTHORIZATION REQUIREMENTS AND CLINICAL CRITERIA

A. Prior Authorization of Non-Urgent Healthcare Service (A.C.A. 23-99-1105)

Evolent (formerly National Imaging Associates, Inc.) acting on behalf of the Health Plan must make an authorization or non-authorization determination and notify the subscriber (member) and provider of the determination/decision within 2 business days of obtaining all information needed to make the determination.

B. Prior Authorization of Urgent Healthcare Service (A.C.A. 23-99-1106) 

Evolent acting on behalf of the Health Plan must make an expedited authorization or adverse determination on an urgent request and notify the subscriber(member) and provider of the determination no later than 1 business day after receipt of all information needed to complete the review.

C. Retrospective Denial (A.C.A. 23-99-1108)

  1. Evolent may not revoke (cancel), limit, condition, or restrict an authorization for a period of 45 business days from the date the provider received the authorization.
  2. Any correspondence, contact, or other action by Evolent that disclaims, denies, or attempts to disclaim, or attempts to deny payment for services that have been authorized within the 45-day period is void.

D. Written Clinical Criteria 

Any written clinical criteria can be found on RadMD and on the Arkansas Clinical Guidelines page. Per AR SB 318 (ACA 23-99-1104) statistics are made readily available regarding prior authorization approvals and denials.

DELAWARE AUTHORIZATION REQUIREMENTS AND CLINICAL CRITERIA

A. Prior Authorization of Non-Urgent Healthcare Service (HB 381)

  1. Evolent (formerly National Imaging Associates, Inc.) acting on behalf of the Health Plan must make an authorization or non-authorization determination and notify the subscriber (member) and provider of the non-electronic determination/decision within 8 business days of receipt of preauthorization request that contains all necessary information not to exceed 15 calendar days.
  2. Evolent acting on behalf of the Health Plan must make an authorization or non-authorization determination and notify the subscriber (member) and provider of the electronic determination/decision within 5 business days of receipt of the complete electronic request not to exceed 15 calendar days.
  3. Preauthorization for a health care service shall be valid for a reasonable and customary period of time for the service but no less than 60 days from the date that the provider receives the preauthorization, subject to confirmation of continued coverage and eligibility. 
  4. Any written clinical criteria can be found on RadMD.

Services requiring preauthorization for Delaware Health Plans:

CT scan of:  head/brain/sinus/soft tissue of the neck/ chest (non coronary)/ pelvis/cervical spine/lumbar spine/ thoracic spine/lower extremity/abdomen/heart/heart congenital studies, noncoronary arteries

CT angiography of:  chest/pelvis/upper extremity/lower extremity/ abdomen/pelvis/abdominal arteries

MRI of:  the face/neck/brain/cervical spine/lumbar spine/thoracic spine/upper joint extremity/lower extremity/hip/abdomen/heart/breast1

MRA of:  head/neck/chest (excluding myocardium)/spinal canal/pelvis/upper extremity/lower extremity/abdomen

PET scan of:  heart/brain PET PET Scan with concurrently acquired CT for attenuation correction and anatomic, localization. PET imaging whole body, melanoma for non-covered indications/ PET imaging, any site, not otherwise specified/ PET imaging, initial diagnosis of breast cancer and/or surgical planning for breast cancer

Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography)

Coronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CT

CTA coronary arteries (CCTA)

MR Spectroscopy

Myocardial Perfusion Imaging – Nuclear Cardiology Study

Low Dose CT For Lung Cancer Screening

Mandatory notification required for stress Echocardiography

1 Breast MRI does not require preauthorization for Exchange members

ILLINOIS PRIOR AUTHORIZATION OF HEALTHCARE SERVICES AND CLINICAL CRITERIA

(compliance with Illinois 215 ILCS 200/25 & 200/30)

  1. Evolent (formerly National Imaging Associates, Inc.) acting on behalf of the Health Plan must complete an authorization determination and notify the subscriber (member) and provider of the determination/decision for non-urgent requests within 5 calendar days after receipt of a preauthorization request that contains all necessary information, but not to exceed 15 calendar days after receipt of the request.
  2. Evolent acting on behalf of the Health Plan must complete an authorization determination and notify the subscriber (member) and provider of the determination/decision for urgent requests within 48 hours after receipt of a preauthorization request that contains all necessary information, but not to exceed 72 hours after receipt of the request.
  3. Any written clinical criteria can be found on RadMD. Illinois prior authorization state reports are also available. 

 

Services requiring preauthorization for Illinois Health Plans:

  Radiology / Cardiac:

  • CT scan of:  head/brain/sinus/soft tissue of the neck/chest (non coronary)/ pelvis/cervical spine/lumbar spine/thoracic spine/lower extremity/abdomen/heart/heart congenital studies, noncoronary arteries
  • CT angiography of:  chest/pelvis/upper extremity/lower extremity/ abdomen/pelvis/abdominal arteries
  • MRI of:  the face/neck/brain/cervical spine/lumbar spine/ thoracic spine/upper joint extremity/lower extremity/hip/abdomen/heart/breast1
  • MRA of:  head/neck/ chest (excluding myocardium)/ spinal canal/pelvis/upper extremity/lower extremity/abdomen
  • PET scan of:  heart/brain; PET Scan with concurrently acquired CT for attenuation correction and anatomic, localization. PET imaging whole body, melanoma for non-covered indications/ PET imaging, any site, not otherwise specified/ PET imaging, initial diagnosis of breast cancer and/or surgical planning for breast cancer
  • Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography)
  • Coronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CT
  • CTA coronary arteries (CCTA)
  • MR Spectroscopy
  • Myocardial Perfusion Imaging – Nuclear Cardiology Study
  • Stress Echocardiography
  • Echocardiography (TTE/TEE)
  • Low Dose CT For Lung Cancer Screening
  • MUGA Scan

 Physical Medicine:

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy

 Interventional Pain Medicine:

  • Sacroiliac Joint Injection
  • Cervical/Thoracic Interlaminar Epidural
  • Cervical/Thoracic Transforaminal Epidural
  • Lumbar/Sacral Interlaminar Epidural
  • Lumbar/Sacral Transforaminal Epidural
  • Cervical/Thoracic Facet Joint Block
  • Lumbar/Sacral Facet Joint Block
  • Cervical/Thoracic Facet Joint Radiofrequency Neurolysis
  • Lumbar/Sacral Facet Joint Radiofrequency Neurolysis

1 Breast MRI does not require preauthorization for Exchange members

MASSACHUSETTS STANDARD IMAGING PRIOR AUTHORIZATION FORMS

Chapter 176O Section 25 of the Massachusetts General Laws requires that health insurance carriers use standard prior authorization forms when reviewing requests for certain imaging services.

Based on the work of the Mass Collaborative, an organization of health plans, provider organizations and professional associations, standard prior authorization request forms have been developed and approved by the Massachusetts Division of Insurance (DOI). These forms will be accepted by all health plans.

Effective November 1st Evolent, (formerly National Imaging Associates, Inc.) will begin accepting the following imaging prior authorization forms approved by the DOI. Completed forms can be faxed to Evolent at 1-888-656-6648.  Providers can also continue to submit prior authorization requests through the Evolent Call Center and RadMD. 

This change applies to members in Fully Insured Massachusetts plans including PPO, POS and HMO.

Cardiac Imaging 
CT/CTA/MRI/MRA 
PET-PET CT


MASSACHUSETTS AUTHORIZATION REQUIREMENTS AND CLINICAL CRITERIA

A. Prior Authorization of Non-Urgent Healthcare Service

Evolent (formerly National Imaging Associates, Inc.) acting on behalf of the Health Plan must make an authorization or non-authorization determination and notify the subscriber (member) and provider of the determination/decision within two (2) business days of obtaining all information needed to make the determination. The rendering provider must be notified of the decision by telephone within twenty-four (24) hours thereafter.

B. Prior Authorization of Urgent Healthcare Service

Evolent acting on behalf of the Health Plan must make an expedited authorization or adverse determination on an urgent request and notify the subscriber (member) and provider of the determination no later than seventy-two (72) hours of receipt of request.

 

NEW MEXICO AUTHORIZATION REQUIREMENTS AND CLINICAL CRITERIA

A. Prior Authorization of Non-Urgent Healthcare Service (NMAC 13.10.31.8)

  1. Evolent (formerly National Imaging Associates, Inc.) acting on behalf of the Health Plan must make an authorization or non-authorization determination within the below timeframes:

NM ST § 59A-22B-5 

  1. 7 business days upon receipt of necessary information otherwise it is deemed approved.
  2. 24 calendar hours from request for expedited cases otherwise deemed approved.
  3. Any written clinical criteria can be found on RadMD.

For Presbyterian Health Plan, Inc and Presbyterian Insurance Company, Inc. only:

Presbyterian utilizes the Uniform Prior Authorization Form pursuant to the New Mexico Administrative Code (NMAC) 13.10.31.10. The form may be found here.

RBM/Cardiac Services requiring preauthorization for all New Mexico Health Plans: 

CT scan of:  head/brain/sinus/soft tissue of the neck/ chest (non coronary)/ pelvis/cervical spine/lumbar spine/ thoracic spine/lower extremity/abdomen/heart/heart congenital studies, noncoronary arteries

CT angiography of:  chest/pelvis/upper extremity/lower extremity/abdomen/pelvis/abdominal arteries

MRI of:  the face/neck/brain/cervical spine/lumbar spine/thoracic spine/upper joint extremity/lower extremity/hip/abdomen/heart/breast1

MRA of:  head/neck/chest (excluding myocardium)/spinal canal/pelvis/upper extremity/lower extremity/abdomen

PET scan of:  heart/brain PET PET Scan with concurrently acquired CT for attenuation correction and anatomic, localization. PET imaging whole body, melanoma for non-covered indications/PET imaging, any site, not otherwise specified/PET imaging, initial diagnosis of breast cancer and/or surgical planning for breast cancer

Diagnostic CT colonoscopy (virtual colonoscopy, CT colonography)

Coronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CT

CTA coronary arteries (CCTA)

MR Spectroscopy

Myocardial Perfusion Imaging – Nuclear Cardiology Study

Low Dose CT For Lung Cancer Screening

Stress Echocardiography

MSK Services requiring preauthorization for Presbyterian Health Plan:

Spine Surgery (Lumbar and Cervical)

Therapy Services requiring preauthorization for Western Sky Health Plan:

Physical Therapy, Speech Therapy, and Occupational Therapy

1 Breast MRI does not require preauthorization for Exchange members