National Imaging Associates (NIA) - Outpatient Radiology Authorization
AmeriHealth Caritas Pennsylvania’s radiology benefits vendor, National Imaging Associates, Inc. (NIA), provides utilization management review and authorization for non-emergent, advanced, outpatient imaging procedures.
The following non-emergent, advanced, outpatient imaging procedures require prior authorization through NIA:
- PET scan
- Nuclear cardiology/Nuclear stress/MPI
The following services do not require authorization through NIA:
- Inpatient advanced imaging services.
- Observation setting advanced imaging services.
- Emergency room imaging services.
- AmeriHealth Caritas Pennsylvania will continue to perform prior authorization of coverage for interventional radiology procedures (even those that utilize MR/CT technology).
The ordering facility or provider must obtain the appropriate prior authorization via NIA’s website or by calling NIA at 1-800-424-5657.
If an urgent/emergent clinical situation exists outside of a hospital emergency room, please contact NIA immediately at the number above with the appropriate clinical information for an expedited review.
- Name and office phone number of ordering physician.
- Member name and ID number.
- Requested examination.
- Name of provider office or facility where the service will be performed.
- Details justifying the examination.
- Anticipated date of service (if known).Symptoms and their duration (including cardiac symptoms, risk factors and related history when requesting cardiac services).
- Physical exam findings (including findings applicable to the requested services, e.g. for cardiac services, include BMI, blood pressure, whether or not patient is a smoker, history of diabetes or hypertension, family history, etc.).
- Conservative treatment patient has already completed (e.g. physical therapy, chiropractic or osteopathic manipulation, hot pads, massage, ice packs and medication).
- Results and/or reports of preliminary procedures already completed (e.g. X-rays, CTs, lab work, ultrasound, scoped procedures, referrals to specialist and specialist evaluation). For cardiac services, include total cholesterol, ECG results, HDL level, problems with exercise capacity and results of previous cardiac evaluation procedures (e.g. stress test, echocardiogram, catheterization, etc.).
- Reason the study is being requested (e.g. further evaluation, rule out a disorder).
- Please be prepared to forward the following information, if requested:
- Clinical notes.
- Reports of previous procedures.
- Specialist reports/evaluation
- Call center hours of operation are Monday through Friday, 8am to 8 pm, EST. You may obtain prior authorization by calling 1-800-424-5657.
- NIA can accept multiple requests during one phone call.
RadMD Website Access
- Prior authorization self-service is available at RadMD. RadMD is available 24 hours per day, seven days per week, except when maintenance is performed once every other week after business hours.
- To begin with, you will need to obtain a unique user name and password for each individual user in your office. Simply go to the RadMD website, select "New User" button and complete the application form.
- If requesting authorization through NIA’s website and your request is pended, you will receive a tracking number, and NIA will contact you to complete the process.
- The NIA website cannot be used for retrospective or expedited authorization requests. Those requests must be processed by calling NIA at 1-800-424-5657.
The rendering facility or provider must verify that prior authorization was obtained prior to rendering the service. To verify, got to NIA’s website or call NIA at the plan-specific phone numbers above. Payments are denied for procedures performed without the required authorization; members cannot be balance-billed for these procedures.
Other items to note:
- Authorizations are valid for 60 days from the date of the initial request.
- The NIA authorization number consists of eight or nine alpha/numeric characters. In some cases, you may instead receive an NIA tracking number (not the same as an authorization number) if your authorization request is not approved at the time of initial contact. You can use either number to track the status of the request on the RadMD website or via NIA’s Interactive Response telephone system.
- For prior authorization complaints/appeals, please follow the instructions on the denial letter.
- NIA’s Clinical Guidelines can be found on NIA’s website under “Online Tools/Clinical Guidelines.” NIA’s guidelines for the use of imaging examinations have been developed from practice experience, literature reviews, specialty criteria sets and empirical data.
- An authorization number is not a guarantee of payment. Whether the requested service is covered is subject to all the terms and conditions of the member’s benefit plan, including but not limited to member eligibility and benefit coverage at the time the services are provided.
- There is no change in claims submission. AmeriHealth Caritas Pennsylvania is responsible for the payment and resolution of all outpatient radiology claims and claims payment issues. Claims continue to go directly to AmeriHealth Caritas Pennsylvania at:
Claims Processing department
P.O. Box 7118
London, KY 40742
Providers are encouraged to use Payer ID number 77001 for EDI claims submissions.
- NIA FAQ for Providers (PDF)
- Cardiac Prior Authorization Checklist (PDF)
- Cardiac FAQ (PDF)
- Utilization Review Coding Matrix (PDF)
- Tip Sheet for Ordering Advanced Imaging Studies (PDF)