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Welcome  » September 30, 2022 10:55 PM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Radiology
09/30/2022  

Prior Authorization : General Information

Topic #10721

An Overview

Most advanced imaging services, including CT, MR, MRE, and PET imaging, require PA when performed in either outpatient hospital settings or in non-hospital settings (e.g., radiology clinics). eviCore healthcare, a private radiology benefits manager, is authorized to administer PA for advanced imaging services on behalf of ForwardHealth. Providers work directly with eviCore healthcare and should submit to eviCore healthcare all information necessary to make a PA determination. eviCore healthcare uses approved national clinical guidelines for imaging services when making PA determinations.

The provider who orders the advanced imaging service (e.g., the member's primary care physician, the member's specialist) is required to work with eviCore healthcare to complete and submit the PA request for the service, unless this provider has been granted an exemption from PA requirements for CT, MR, and MRE services.

The provider or facility that renders the service should do the following prior to rendering the service:

  • Verify the member's enrollment.
  • Verify with eviCore healthcare (or with the ordering provider) that a PA has been approved for the member.
  • If no PA is on file with ForwardHealth, verify with the ordering provider that they are exempt from PA requirements. If this is the case, include modifier Q4 on the claim detail for the CT, MR, or MRE imaging service.

If ForwardHealth has not granted an exemption, PA requirements apply to advanced imaging services for fee-for-service members enrolled in the following ForwardHealth programs:

  • Medicaid
  • BadgerCare Plus
  • EE for Children
  • EE for Pregnant Women

PA is also required for members enrolled in state-contracted MCOs who receive physician and radiology services on a fee-for-service basis (e.g., Children Come First).

Topic #10722

Communication with Members

ForwardHealth recommends that providers inform members that PA is required for certain specified services before delivery of the services. Providers should also explain that, if required to obtain PA, they will be submitting member records and information to eviCore healthcare on the member's behalf. Providers are required to keep members informed of the PA request status throughout the entire PA process.

Topic #435

Definition

PA is the electronic or written authorization issued by ForwardHealth to a provider prior to the provision of a service. In most cases, providers are required to obtain PA before providing services that require PA. When granted, a PA request is approved for a specific period of time and specifies the type and quantity of service allowed.

Topic #10723

Prior Authorization Numbers

Each PA request for advanced imaging services is assigned a unique PA number by eviCore healthcare. This number identifies valuable information about the PA. The following table provides detailed information about interpreting the PA number.

Type of Number and Description Applicable Numbers and Description
Media — One digit indicates media type. PA requests received by eviCore healthcare for advanced imaging services are always identified with media type "9."
Year — Two digits indicate the year eviCore healthcare received the PA request. For example, the year 2010 would appear as 10.
Julian date — Three digits indicate the day of the year, by Julian date, that eviCore healthcare received the PA request. For example, February 3 would appear as 034.
Sequence number — Four digits indicate the sequence number. The sequence number is used internally by eviCore healthcare.
Topic #436

Reasons for Prior Authorization

Only about 4 percent of all services covered by Wisconsin Medicaid require PA. PA requirements vary for different types of services. Refer to ForwardHealth publications and Wis. Admin. Code ch. DHS 107 for information regarding services that require PA. According to Wis. Admin. Code § DHS 107.02(3)(b), PA is designed to do the following:

  • Safeguard against unnecessary or inappropriate care and services
  • Safeguard against excess payments
  • Assess the quality and timeliness of services
  • Promote the most effective and appropriate use of available services and facilities
  • Determine if less expensive alternative care, services, or supplies are permissible
  • Curtail misutilization practices of providers and members

PA requests are processed based on criteria established by the Wisconsin DHS.

Providers should not request PA for services that do not require PA simply to determine coverage or establish a reimbursement rate for a manually priced procedure code. Also, new technologies or procedures do not necessarily require PA. PA requests for services that do not require PA are typically returned to the provider. Providers having difficulties determining whether or not a service requires PA may call Provider Services.

Topic #438

Reimbursement Not Guaranteed

Wisconsin Medicaid may decline to reimburse a provider for a service that has been prior authorized if one or more of the following program requirements is not met:

  • The service authorized on the approved PA request is the service provided.
  • The service is provided within the grant and expiration dates on the approved PA request.
  • The member is eligible for the service on the date the service is provided.
  • The provider is enrolled in Wisconsin Medicaid on the date the service is provided.
  • The service is billed according to service-specific claim instructions.
  • The provider meets other program requirements.

Providers may not collect payment from a member for a service requiring PA under any of the following circumstances:

  • The provider failed to seek PA before the service was provided.
  • The service was provided before the PA grant date or after the PA expiration date.
  • The provider obtained PA but failed to meet other program requirements.
  • The service was provided before a decision was made, the member did not accept responsibility for the payment of the service before the service was provided, and the PA was denied.

There are certain situations when a provider may collect payment for services in which PA was denied.

Other Health Insurance Sources

Providers are encouraged, but not required, to request PA from ForwardHealth for covered services that require PA when members have other health insurance coverage. This is to allow payment by Wisconsin Medicaid for the services provided in the event that the other health insurance source denies or recoups payment for the service. If a service is provided before PA is obtained, ForwardHealth will not consider backdating a PA request solely to enable the provider to be reimbursed.

Topic #10725

Requesting Prior Authorization

Providers who order advanced imaging services should obtain PA for the services from eviCore healthcare because they likely have the most immediate access to the clinical information necessary to complete the PA request. ForwardHealth allows any provider who can order advanced imaging services within their scope of practice to complete and submit a PA request for advanced imaging services.

eviCore healthcare utilizes evidence-based clinical guidelines derived from national medical associations' recommendations to determine the medical necessity and appropriateness of the requested service(s). The guidelines are published on the eviCore healthcare Portal. eviCore healthcare will make a PA determination based on current ForwardHealth policy in conjunction with the eviCore healthcare guidelines. Providers are reminded that an approved PA does not guarantee reimbursement for the service.

Providers will be required to establish an account on the eviCore healthcare Portal to view the guidelines. Providers without internet access can call eviCore healthcare at 800-575-4517 for a copy of the guidelines on CD.

The provider or facility who renders the advanced imaging service and submits a claim for the service should verify with eviCore healthcare or with the ordering provider that an approved PA is on file for the member prior to rendering the service. Providers can verify PA through the eviCore healthcare Portal or by contacting eviCore healthcare via telephone. If no PA is on file for the member, the provider rendering the services may request the PA prior to rendering the service if the provider can provide eviCore healthcare with the required clinical data. Providers should note that PA information for advanced imaging services will not display on the ForwardHealth Portal. Providers should always refer to eviCore healthcare to verify PA for advanced imaging services.

Information Required When Requesting PA

Providers should have the following member and clinical information on hand when submitting a PA request to eviCore healthcare on the eviCore healthcare Portal, on the telephone, or via fax:

  • The member's full name, date of birth, and address
  • The member's ForwardHealth member ID number
  • The member's working or differential diagnosis
  • Prior tests, lab work, and/or imaging performed related to the member's diagnosis
  • Type and duration of treatment performed to date for the diagnosis
  • Requested imaging service (e.g., "MRI of the brain") or requested procedure code if known (Note: PA requests for advanced imaging services do not require modifiers even if the procedure code is billed with a modifier.)
  • A Medicaid-enrolled rendering facility (Note: Members may choose a different Medicaid-enrolled rendering facility than the one submitted to eviCore healthcare with the PA request. Amendments to the PA request are not required for a change in the rendering facility.)

Having complete member and clinical information ready will expedite the PA determination process.

Topic #10724

eviCore healthcare Portal

Providers are encouraged to set up an account with eviCore healthcare online via the eviCore healthcare Portal. An eviCore healthcare Portal account allows ordering providers and providers who render services to perform the following business functions:

  • Submit PA requests for advanced imaging services.
  • Verify that an approved PA is on file for a member.
  • View eviCore healthcare guidelines for making PA determinations.

For technical assistance with the eviCore healthcare Portal, providers may contact eviCore healthcare Portal Support by email at portal.support@evicore.com or by phone at 800-646-0418 ext. 20136.

 
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