National Imaging Associates (NIA)

Radiology

Louisiana Healthcare Connections has contracted with National Imaging Associates Inc. (NIA), an affiliate of Magellan Health Services, for radiology benefit management.

The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

Louisiana Healthcare Connections oversees the NIA program and is responsible for claims adjudication. NIA manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.

Prior authorization is required for the following outpatient radiology procedures:

  • CT/CTA/CCTA
  • MRI/MRA
  • PET Scan

Key Provision:

Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.

Go to the NIA website for more information.

Therapy Services (PT, OT, ST)

Effective March 1, 2019, physical medicine services (physical therapy, occupational therapy and speech therapy) will no longer be managed through a post-service review process for Louisiana Healthcare Connections.  Louisiana Healthcare Connections remains committed to ensuring that physical medicine services provided to our members are consistent with nationally recognized clinical guidelines.  Therefore, the utilization management of these services will be managed by National Imaging Associates, Inc. (NIA) through a prior authorization program.  All providers will be required to obtain prior authorization for Physical Medicine services. 

NIA Call Center will be available to submit requests for prior authorization for dates of service March 1, 2019, and beyond. Any services rendered on and after March 1, 2019, will require prior authorization.

There are two ways to submit prior authorization: Through NIA’s Website at www.RadMD.com, or by calling NIA at 1-866-326-6301.  When requesting an authorization, please provide the name, address and TIN of the facility that will be used for billing the services.  Payments will be denied for services performed without a necessary prior authorization, and the member cannot be balance-billed for such services.

You will be able to upload requested records on the NIA website www.RadMD.com or through the NIA fax number at 1-800-784-6864.  Medical necessity reviews are based on clinical guidelines which are available on the NIA website.

For more information, please see our Louisiana Healthcare Connections Physical Medicine Prior Authorization Quick Reference Guide for Providers (https://www.louisianahealthconnect.com/content/dam/centene/louisiana-health-connect/pdfs/medicaid-provider/NIA_Physical_Medicine_QRG.pdf)

 

Interventional Pain Management

Evolent manages non-emergent outpatient prior authorizations for Interventional Pain Management (IPM) procedures. It is the responsibility of the ordering physician to obtain authorization for all IPM procedures outlined below. Outpatient IPM procedures requiring prior authorization include:

  • Spinal Epidural Injections
  • Paravertebral Facet Joint Injections or Blocks
  • Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis)
  • Sacroiliac Joint Injections
  • Spinal Cord Stimulators

Note: A separate prior authorization number is required for each procedure ordered. Prior authorization is not required through Evolent for services performed in the emergency department, on an inpatient basis or in conjunction with a surgery. Prior authorization and/or notification of admission is still required through New Hampshire Healthy Families. To obtain authorization through Evolent, visit RadMD.com or call 866-249-1581.

Musculoskeletal Care Management (MSK)

In keeping with our commitment of promoting continuous quality improvement for services provided to Louisiana Healthcare Connections members, we have partnered with Evolent to implement a Musculoskeletal Care Management (MSK) program. This program includes prior authorization for non-emergent MSK procedures for Louisiana Healthcare Connections members. This decision is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.

How the Program Works

MSK Surgeries: Prior authorization will be required for the following non-emergent inpatient and outpatient hip, knee, shoulder, lumbar and cervical surgeries:

Hip

  • Revision/Conversion Hip Arthroplasty
  • Total Hip Arthroplasty/Resurfacing
  • Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincher & labral repair)
  • Hip Surgery – Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)

Knee

  • Revision Knee Arthroplasty
  • Total Knee Arthroplasty (TKA)
  • Partial-Unicompartmental Knee Arthroplasty (UKA)
  • Knee Manipulation under Anesthesia (MUA)
  • Knee Ligament Reconstruction/Repair
  • Knee Meniscectomy/Meniscal Repair/Meniscal Transplant
  • Knee Surgery – Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)

Shoulder

  • Revision Shoulder Arthroplasty
  • Total/Reverse Shoulder Arthroplasty or Resurfacing
  • Partial Shoulder Arthroplasty/Hemiarthroplasty
  • Shoulder Rotator Cuff Repair
  • Shoulder Labral Repair
  • Frozen Shoulder /Adhesive Capsulitis Repair
  • Shoulder Surgery – Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)

Cervical

  • Cervical Anterior Decompression with Fusion –Single & Multiple Levels
  • Cervical Posterior Decompression with Fusion –Single & Multiple Levels
  • Cervical Posterior Decompression (without fusion)
  • Cervical Artificial Disc Replacement – Single & Two Levels
  • Cervical Anterior Decompression (without fusion) 

Lumbar

  • Lumbar Microdiscectomy
  • Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy & Foraminotomy)
  • Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single & Multiple Levels
  • Lumbar Artificial Disc – Single & Multiple Levels

Sacroiliac

  • Sacroiliac Joint Fusion

As a part of the Evolent clinical review process, actively practicing, orthopedic surgeon specialists (hip, knee, and shoulder) or neurosurgeons (spine) will conduct the medical necessity reviews and determinations of musculoskeletal surgery cases.

Please refer to the “Solutions” tab on the Evolent home page (https://www1.RadMD.com) for additional information on the MSK program. Checklists and tip sheets are available there to help providers ensure surgical procedures are delivered according to national clinical guidelines.

Should you have questions, please contact Evolent at 866-249-1581.