As of January 1, 2021 the following MVP Plans will no longer require prior authorization for High Tech Radiology Services:
MVP Medicare Advantage Plans
MVP Medicaid Managed Care
MVP Harmonious Health Plan (HARP)
MVP Child Health Plus (CHP)
These services include: MRI/MRA, PET Scan, Nuclear Cardiology, CT/CTA, and 3D Rendering Imaging Services
This applies only to the services rendered by IN Network Providers. For any of the above mentioned plans that do have Out of Network benefits and would like to go to an out of network provider: the Prior Authorization is Required!
To request an authorization: please complete a Prior Approval Request Form (PARF) and fax it to MVP at 1-800-280- 7346.
ALL other MVP plans still require a prior authorization for HIGH Radiology Services. To request an Auth please contact eviCore Healthcare by submitting requests at evicore.com or by calling 1-800-568-0458.
This policy is for site of care medical necessity review and it only applies to administration performed in an outpatient hospital setting.
This does not apply to requests for review of medication administration performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Empire is the secondary payer.
The medical necessity Review will be performed by AIM Specialty Health® (AIM).
AIM will evaluate the clinical information in the request to the CG-MED-083 policy, or Site of Care: Specialty Pharmaceuticals, to determine if the hospital-based outpatient setting is medically necessary for the medication administration. To see the policy and what clinical considerations are taken into account for determination, visit Empire’s Medical Policy and Clinical UM Guidelinepage and type Specialty in the search field. You may contact AIM to request a peer-to-peer discussion before or after the determination.
The following codes apply to this policy:
To Submit a request for review:
Starting May 16, 2021, ordering providers may submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after June 1, 2021 to AIM in one of the following ways:
Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
**Note: In some plans “level of care” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “site of care” and in some plans, these terms may be used interchangeably. For simplicity, we will hereafter use “site of care.”**