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Disclaimer: UM decisions are made only on appropriateness of care, services and existence of coverage as determined by the health plan. Financial incentives are not based on utilization decisions.For assistance, email RCSupport@HealthHelp.com or call 1-800-546-7092 Mon-Fri 7a-7p (Central Time). To receive a copy of the clinical rationale used in the case, please contact HealthHelp's Clinical Guidelines Department at 877-685-5264.
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2020 Additional Codes Requiring Preauthorization
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- Fax: 1-888-863-4464; Fax Forms
Reminder: When faxing requests, please ensure that you're entering the correct fax number prior to sending the fax to avoid HIPAA privacy incidents.
- Powell AC, Rogstad TL, Jacob NM, Long JW, Deshmukh UU, Loy BA, Mirhadi AJ. The Association between Use of Hypofractionation and Treatment Completion among Recipients of Radiation Therapy Post-Mastectomy, Practical Radiation Oncology. 2020 Jul 1;10(4):e244-9.
- Powell AC, Rogstad TL, Winchester DE, Shanser JD, Long JW, Deshmukh UU, Rao VM. Discordance in Clinical Recommendations Regarding the Use of Imaging. American Journal of Medical Quality. 2020 Mar;35(2):117-24.
- Powell AC, Wang Y, Smith GL, Long JW, Deshmukh UU, Friedman DP, Roth CG, Sundaram B. Outpatient facility-based order variation in combined imaging. PloS one. 2019 Nov 14;14(11):e0224735.
- Powell AC, Lugo CT, Wang Y, Smith GL, Long JW, Deshmukh UU, Robinson JD. Modification and Reinitiation of Lower Back Imaging Orders After Evidence-Based Collaborative Consultation. Academic Radiology. 2019 Nov 1;26(11):1450-6.
- Powell AC, Rogstad TL, Elliott SW, Price SE, Long JW, Deshmukh UU, Murad MH, Steffen MW. Health care utilization and pain outcomes following early imaging for low back pain in older adults. The Journal of the American Board of Family Medicine. 2019 Nov 1;32(6):773-80.
Helpful Links
Site
HealthHelp has developed a set of minimum criteria that providers should meet to ensure a consistent level of services. HealthHelp's Site program assesses the Facility requirements, Professional Qualifications, Equipment, and Quality and Patient Safety as part of its programs. Humana has contracted with Site to perform the assessment with the aim of achieving a quality certified network.
SITE Mission
Our mission is to identify opportunities for imaging facilities, including freestanding and physician offices, to achieve a high level of quality that benefits all members of the healthcare continuum.
HealthHelp offers the following programs for Site Certification:
Click on each program to learn more!
DiagnosticSite
The DiagnosticSite™ Assessment Program is a medical imaging safety and quality program designed to assess the medical imaging equipment, personnel, and policies of facilities that perform diagnostic imaging services.
Login to continue or update your assessment. Don’t have an account, click Register to get started!
Click here to register for a Webinar.
HealthHelp SITE Certified Provider Directory
Call us at 1-800-506-2560 or email us at SiteSupport@healthhelp.com today!
Over 29,000 facilities have participated, with more than 89,000 imaging devices assessed for quality.
Improved imaging quality produces the most consistent and efficient path to appropriate treatment and accurate diagnosis.
Scope
Imaging and Interpretation Criteria
Humana has contracted with HealthHelp to assist in applying diagnostic imaging and interpretation criteria by clinical specialty. These criteria extend reimbursement of imaging to certain nonradiologist specialists based on the educational program requirements as listed in the American Medical Association (AMA) Graduate Medical Education Directory, medical literature and an advisory board review. These guidelines require continuing medical education (CME) credit and an associated number of supervised procedures, as well as additional education in patient safety and technique.
The diagnostic imaging and interpretation criteria provide an opportunity for reduction in both costs and medical errors, while at the same time working to improve overall quality and patient safety.
You may request additional permissible codes if you meet any of the following criteria:
- The primary specialty listed on your letter is incorrect.
- You have been given privileges to interpret diagnostic imaging at a hospital.
- You can provide documentation of your specific training and/or certification in performing and interpreting diagnostic imaging outside of what is required for your primary specialty (subspecialty, dual board certified, or certification from approved program).
- You can demonstrate extensive professional expertise in the absence of board eligibility or specific training or certification (combination of CME hours and supervised procedures).
- You can provide documentation that you have contracted with a radiologist/cardiologist to interpret your images.
Supporting documentation should be included in order to process your application for the following:
- For incorrect specialty:
- Specialty board certification; or
- Medical License Number
- For hospital privileges:
- Letter signed by hospital administrator and on office letterhead stating the physician has privileges to interpret the codes
- For training and or/certification:
- Certificate from a HH approved program. Click here for list.
- Copy of board certification in something other than listed for primary specialty
- For professional experience:
- Documentation of the completion of CME hours specific to modality requested; AND
- Letter of attestation from facility personnel or training logs with proctor sign offs that meets minimum number of supervised procedures by modality.
- Click here for requirements by modality.
- For contract with Radiologist / Cardiologist:
- Copy of original contract or a letter of agreement that includes all the following criteria:
- Signed by both parties
- Lists the modalities being interpreted by Radiologist/Cardiologist
- Includes effective date and terms of renewal or end date
- Lists at least one radiologist name interpreting with NPI or license number.
- Copy of original contract or a letter of agreement that includes all the following criteria:
If you have received a notification and would like to request additional permissible codes, please click here to fill out a consideration application.
Permissible Codes
For a listing of permissible codes by modality/body, click here.
For a list of supporting articles, click here.
Help Topics
Physicians who have adequate training in imaging interpretation and acquisition for which they perform and bill will not experience any change in the process.
Yes. The focus is to confirm that trained health care providers are conducting and interpreting imaging studies. The health care provider must submit specific training and/or certification for performing or interpreting diagnostic imaging. Please refer the provider here or call HealthHelp at (866)-710-9155.
Specific imaging studies are CT, MRI, PET, cardiac nuclear medical studies, bone densitometry, fluoroscopy, and ultrasound.
Affected procedure codes include 70000 series excluding plain film, mammography, most interventional codes and radiation oncology; 90000 series including only vascular ultrasound and echocardiography; and corresponding select category III codes.
Radiography (“plain film,” or “x-rays”) is not overseen by Imaging and Interpretation Criteria; this will cause no change in reimbursement to physicians who bill for this modality.
Specific imaging studies are CT, MRI, PET, cardiac nuclear medical studies, bone densitometry, fluoroscopy, and ultrasound.
Upon receipt and review of documentation submitted by the physician during the consideration application process, HealthHelp’s evaluation will confirm that the organization certifying the educational activity is an accredited CME provider by searching the list of Accreditation Council for Continuing Medical Education (ACCME) and state-medical-society-accredited providers on the ACCME website (www.accme.org). The determination of the hours assigned to the program are determined by the AMA Physician's Recognition Award (PRA) credit system, which has become the CME standard for licensing boards and specialty organizations nationwide and is recognized by all U.S. jurisdictions.The sum of the hours submitted will be compared to HealthHelp’s minimum standards criteria. If the sum total of the hours submitted is equal to or greater than the minimum required, the consideration request will be approved and the health care provider will be notified of the additional permissible codes. If the sum total of the hours submitted is not equal to the minimum required, the consideration request will be denied and the health care provider will be notified of the decision and the approved permissible codes will be restated.
If a health care provider submits training hours that are not part of a formalized training program, HealthHelp will compare the information to the AMA PRA Category 2 credit requirements. For full details on those requirements, visit http://www.ama-assn.org/ama/pub/education-careers/continuing-medical-education/physicians-recognition-award-credit-system/full-text-booklet.page.
A: HealthHelp’s evaluation process to determine supervised procedures equivalency for training and experience will be identified through the following two components:
- Submitted training logs (to include patient name and services rendered with dates) in which the candidate is rendering an interpretation both physically in the imaging suite and/or interpreted through teleradiography or training software programs
- Letter of supervisor attestation of completion from the mentor who provided the over read (i.e., supervision of study) and feedback on the accuracy of his/her interpretation
Upon receipt of supporting documentation, HealthHelp will make a determination on the application within two weeks. You may obtain status of your application by contacting HealthHelp at 1-866-710-9155.
For general information, contact HealthHelp at 1-866-710-9155 and a customer service representative will help you through the process.
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The user will be given access to information which in some cases might include individually identifiable health information, which is considered private, privileged and confidential. Such information is deemed to be Covered Information for purposes of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), P.L. 104-191. The user is required to maintain the private, privileged and confidential status of the Covered Information. The user is prohibited from further using or disclosing the Covered Information for any purpose other than the purpose for which access is granted. Please acknowledge these terms by logging in. If the user logs in, it is intended to be the legal equivalent of the user’s signature on a written document and equally binding. The user will be given access only by logging in.