Prior Authorizations (PA) for CT and PET Scans: Medically Urgent Requests, CR 41766

June 13, 2014

Effective 5/22/2014, PAs entered into the MIHMS Health PAS Online Portal for some Computed Tomography (CT) and Positron Emission Tomography (PET) Scans are impacted by the following changes:

MaineCare has one (1) business day to make a determination for CT PAs that are medically urgent. In some cases, these services need to be done on the same day and providers may decide to send the patient to the hospital immediately.

Please note: An Urgent request is not the same as Emergency services. Emergency services do not require PA prior to receiving the service. Emergency services can receive retroactive PAs. (MaineCare Benefits Manual, Chapter I, Section 1.14-1(C))

Prior to this change, when you entered a PA online, the services requested would auto approve for a limited number of codes if the appropriate criteria were met. For the subset of codes listed below, a Medically Urgent attestation has now been added to the process. In the past, the PA for these codes pended for medical review. You will now be asked two questions regarding medical urgency when using the subset below. If you attest that this member needs immediate attention by answering “yes” to both questions, the PA will be auto-approved in real time. If you answer no to either question, the PA request will pend for medical review.

Subset of Codes:

70450,70460,70470,70480,70481,70482,70490,70491,70492,70496,70498,71250,71260, 71270,71275,72125,72126,72127,72128,72129,72130,72131,72132,72133,72191,72192, 72193,72194,72292,73200,73201,73202,73206,73700,73701,73702,73706,74150,74160, 74170,74174,74175,74176,74177,74178,75571,75572,75573,75574,75635

Please note: Effective March 1, 2014, codes 92025, 76376 and 76377 no longer require a PA. Affected claims will be reprocessed.

If you have questions, please contact Provider Services at: 1-866-690-5585 (TTY: 711) Monday – Friday 7:00 AM EST until 6:00 PM EST.