RADIOLOGY

1
RADIOLOGY

• PRIOR AUTHORIZATION

2
The GA Legislature 2006 Budget mandates review of
high cost radiology and imaging procedures
including

• PET Brain
• PET Whole Body
• CT Head
• CT Pelvis/Abdomen
• MRI Brain
• MRI Lumbar Spine
• Obstetrical Ultrasounds

3
Procedures Requiring PA The Department of
Community Health has instituted PA for the
following radiology codes
4
Exceptions

• PA not required for the first two U/S performed
  during a pregnancy for the following codes
  76805, 76810, 76811 76812.
• Radiology procedures do not require PA if
  performed during an inpatient hospital admission.

5
New PA Types

• Two new PA types have been developed for
  radiology requests
• Radiology Physician Office
• Radiology Facility Setting

6
Radiology Physician Office

• Use this PA type for radiology services provided
  in a doctors office or free-standing radiology
  center.

7
Radiology Facility Setting

• Use this PA type for radiology services provided
  in an outpatient hospital or ambulatory surgical
  center.

8
Additional Information

• An Additional Information web page has been added
  to each PA type to capture code-specific clinical
  information.
• Each radiology code group has a different
  Additional Information page.

9
Code Entry Restrictions

• Only radiology codes may be entered on a
  Radiology PA request.
• System will not permit entry of the radiology
  procedure codes on any other PA type.

10
How are Requests Submitted?

• Requests for radiology procedures are
  submitted via the GHP Web Portal.
• To register for the Web, go to
• www.ghp.georgia.gov for instructions or call
• the Customer Interaction Center at 404-298-1228
• 1228 (metro Atlanta) or 800-766-4456 (toll free).

11
Radiology PA Process

• When submitted, the case is pended (suspended).
• Cases are reviewed by nurses utilizing InterQual
  criteria and DCH policy guidelines.
• Cases may be approved or denied.
• If denied, Providers may submit a request for
  reconsideration.

12
Notification

• Written notifications are sent for each case
• whether approved or denied.
• Search for the status of a prior authorization
  request via the web