For Dates of Service Before January 1, 2019

An Overview

Most advanced imaging services, including CT, MR, 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 and MR 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 he or she is exempt from PA requirements. If this is the case, include modifier Q4 on the claim detail for the CT or MR 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).