New Quality-Based Radiology Benefit Management Program

Starting July 19, 2010, the MO HealthNet (Medicaid) Division (MHD), in conjunction with Affiliated Computer Services (ACS) and MedSolutions (MSI), will begin implementation of a new quality-based Radiology Benefit Management Program (RBM) for outpatient services.  The RBM program is an expansion of the existing precertification process currently being used for MRIs and CTs of the brain, head, chest and spine.

MSI will begin accepting precertification requests on July 12, 2010 for services scheduled for dates of service July 19, 2010 and beyond at (800) 392-8030.  MedSolutions will begin accepting electronic precertification requests through CyberAccess on July 19, 2010.  To become a CyberAccess user or to obtain training for this new precertification process, contact the ACS Heritage help desk at 1-888-581-9797 or 573-632-9797, or send an e-mail to CyberAcccessHelpdesk at acs-inc.com .  Requests for pre-certification will also be taken by the MHD call center at 1-800-392-8030. 

Effective July 19, precertification requests will be electronically evaluated using robust clinical guidelines.  These guidelines are available on the MSI website (http://www.medsolutions.com/our_difference/guidelines_index.html).  The guidelines are not intended to supersede or replace sound medical judgment, but instead should facilitate the identification of the most appropriate imaging procedure given the participant’s clinical condition. The new RBM program requires precertification for the following procedures: 


·         High-Tech (outpatient, diagnostic, non-emergency MRI, MRA, CT, CTA, and PET scans)
·         Outcomes-Focused Cardiac Imaging (including Nuclear Cardiac (SPECT), EBCT/Calcium Scoring, Transthoracic ECHO, Cardiac PET and PET/CT, Transesophageal ECHO, Diagnostic left-heart catheterization, and Stress ECHO)
·         Ultrasound (outpatient, diagnostic, non-emergency OB and non-OB Ultrasound scans). This is a new policy for ultrasound procedures and affects any provider who may perform ultrasounds listed on the attached procedure list.  Claims with dates of service on or after July 19, 2010 will deny if services are not precertified.  After August 31, 2010 more detailed guidelines will apply to the ultrasound services. A bulletin will be issued to provide additional details.

Please Note:  An approved precertification request does not guarantee payment.  The provider must verify participant MO HealthNet eligibility on the date of service.  Providers can verify MO HealthNet eligibility using the Interactive Voice Response (IVR) System at (573) 635-8908 or by logging on to the MHD website at www.emomed.com.