Radiology Prior Authorization FAQs
- What radiology procedures and/or participants require a prior authorization?
High-tech and cardiac imaging procedure codes require prior authorization (PA) unless they are performed in emergency situations or while the participant is in outpatient observation.
Medicare covered services provided on participants with active Medicare Part B are also exempt from the PA requirement. Participants with Medicare Part C coverage and do not have Qualified Medicare Beneficiary (QMB) benefits are required to obtain a PA.
The MO HealthNet Division (MHD) also requires a PA for certain Cardiac Devices (Pacemakers, Defibrillators, Cardiac Resynchronization Therapy Pacemaker (CRT-P), CRT-Defibrillator (CRT-D), and Subcutaneous Implantable Cardioverter-Defibrillator (SICD)) and Cardiac Interventions (Percutaneous Coronary Intervention (PCI)).
A list of procedure codes requiring a PA can be found on the HealthHelp website.
- How do providers initiate a prior authorization request?
All prior authorization (PA) requests must be initiated by an enrolled MO HealthNet provider and approved by the MO HealthNet Division (MHD). Requests for a PA may be made by using CyberAccess or by calling the Pharmacy and Medical Pre-Certification Helpdesk at (800) 392-8030, option 5.
In order to be approved, PA requests must meet the eligibility criteria established by HealthHelp. Guidelines for the procedures codes are available on the HealthHelp portal.
Ordering providers are responsible for providing a copy of the PA number to the rendering provider for billing purposes. PAs are reviewed and approved an on individual patient basis. Each PA must specify the performing provider. Performing providers must be certified through the DiagnosticSite program in order to receive a referral from an ordering provider.
- Where and how do I search for the facility I wish to perform the scan?
When choosing a performing provider in CyberAccess, ensure that the National Provider Identifier (NPI) and Type of Provider (Taxonomy Code) match the facility location where the procedure is to be performed. When searching for the performing provider, search only by the NPI number.
- How does a provider become certified through the DiagnosticSite program?
By partnering with HealthHelp's Site Assessment Programs, providers are participating in one of the largest quality benchmarking and network credentialing programs designed to signify that professional staff and clinical workflows meet appropriate quality and safety standards.
All enrolled MO HealthNet providers that perform any of the high tech and cardiac imaging procedures listed on the HealthHelp portal must complete their assessment online at the HealthHelp Registration page. The registration process will issue providers a secure login to complete a quality assessment for one or more facilities that provide diagnostic imaging. Providers will be approved for one or more procedures and locations in accordance with the results of their DiagnosticSite assessment, within their submitted scope of practice.
For more information about this process, visit the HealthHelp website.
- How do providers contact DiagnosticSite for assistance?
If providers have questions regarding their DiagnosticSite assessment they should contact HealthHelp at SiteSupport@Healthhelp.com or call (800) 506-2560.
- What happens if a prior authorization request is denied?
When a prior authorization (PA) request is denied, the participant receives a letter outlining the reason for the denial and the procedure for an appeal. The participant must follow the instructions in the letter, within the required timeframes, to request a State Fair Hearing.
Revised October 2024