UH - Managed Care Office

Office of Managed Care Operations

RADIOLOGY SERVICES

University Hospital Referral/Pre-Authorization Requirements

June 2011

MANAGED CARE ORG.	MAMMO- GRAPHY	ROUTINE RADIOLOGY	ULTRASOUND NON OB/GYN	RADIATION THERAPY	NUCLEAR Radiology Procedure	CT SCAN	PET SCAN	MRI	MRA
AETNA Facility ID#: 0010034 Provider Services: 800-624-0756 Member Services: 800-323-9930 Pre-Certification 800-245-1206 NIA Radiology 1-800-648-7299	Script Required (90 Bergen St.) Referral Required If done @ 150 Bergen Street Hospital	Script Required (90 Bergen St) Referral Required If done @ 150 Bergen Street Hospital	Script Required (90 Bergen St) Referral Required If done @ 150 Bergen Street Hospital	Pre-Auth Required *See Note* listed below Regarding Changes	Pre-Auth Required Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required
AMERIGROUP Facility ID #: 10076301 Provider Services: 1-800-454-3730 Ext. x1794 Member Services 1-800-600-4441 Ext : 1788 NIA RADIOLOGY National Imaging Associates, Inc. 1-800-642-7565	Script Required Routine No Precertification Required	Script Required No Precertification Required	Script Required No Precertification Required	Script Required Precertification Required for Coverage of Services Rendered In an Inpatient Setting	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required
United Community Care (formerly) AMERICHOICE Facility ID 221775306 Provider Services: 888-362-3368 Member Services: 800-941-4647 Radiology Prior Authorization Med Solutions 888-693-3211 Fax: 888-693-3210	Script Required Script from PCP or OB/GYN Yes for Ultrasound of Breast	Script Required	Script Required	Script Required Provider must be in Network or Pre-Cert Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required
CIGNA HEALTHCARE Facility ID# 221775306 Provider Services 800-244-6224 Member Services: 800-882-4462 Pre-Certification: 800-244-6224	Managed Care & POS Plans are excluded Must Contact Medical Mgmt. Dept. See Back of patient ID card PPO Plans	Managed Care & POS Plans are excluded Must contact Medical Mgmt. Dept. See Back of patient ID card PPO Plans	Managed Care & POS Plans are excluded Must contact Medical Mgmt. Dept. See Back of patient ID card PPO Plans	Managed Care & POS Plans are excluded Must contact Medical Mgmt. Dept. See Back of patient ID card PPO Plans	Managed Care & POS Plans are excluded Must contact AIM’s @ 18008595288 PPO Plans	Managed Care & POS Plans are excluded Must contact AIM’s @ 18008595288 PPO Plans	Managed Care & POS Plans are excluded Must Contact AIM’s @ 18008595288 PPO Plans	Managed Care & POS Plans are excluded Must contact AIM’s @ 18008595288 PPO Plans	Managed Care & POS Plans are excluded Must contact AIM’s @ 18008595288 PPO Plans
EMPIRE BC Provider Services: 888-476-7245 Medical Mgmt. HMO &POS 800-841-2411 Medical Mgmt. PPO/EPO & Indemnity 800-982-8089	Script Required Must Verify with Medical Mgmt Dept	Script Required Must Verify with Medical Mgmt Dept	Script Required Must Verify with Medical Mgmt Dept.	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required
HORIZON BC/BS Facility ID #310119 Provider Services: 888-666-2535 Member Services: 800-355-2583 Radiology Services Prior Authorization CCN Care Core National 1-866-496-6200	HMO & POS Plans Require Referral (yearly) Mammogram no Referral Required) PPO & Indemnity NO Referral Required	HMO & POS Plans Require Referral PPO & Indemnity NO Referral Required	HMO & POS Plans Require Referral PPO & Indemnity NO Referral Required	HMO & POS Plans Require Pre-Auth Script Required From Ordering Physician with Authorization For Care Core PPO & Indemnity NO Referral	HMO & POS Plans Require Pre-Auth Script Required From Ordering Physician with Authorization For Care Core PPO & Indemnity NO Referral Required	HMO & POS Plans Require Pre-Auth Script Required From Ordering Physician with Authorization For Care Core PPO & Indemnity NO Referral Required	HMO & POS Plan Require Pre-Auth Script Required From Ordering Physician with Authorization For Care Core PPO & Indemnity NO Referral Required	HMO & POS Plans Require Pre-Auth Script Required From Ordering Physician with Authorization For Care Core PPO & Indemnity NO Referral Required	HMO & POS Plans Require Pre-Auth Script Required From Ordering Physician with Authorization For Care Core PPO & Indemnity NO Referral Required
HORIZON NJ HEALTH (formerly Horizon Mercy) Facility ID #1015754 Provider Services: 800-682-9090 Utilization Management 1-800-682-9094 Radiology Prior Authorization NIA Radiology 1-800-642-7299	Script Required No Referral or Authorization Required	Referral Required	Referral Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required	Pre-Auth Required
QUALCARE Facility ID# 221775306 Provider Service: 800-992-6613	PPO Script Required HMO/POS Script Required	PPO Script Required HMO/POS Script Required	PPO Script Required HMO/POS Script Required	PPO Script Required HMO/POS Script Required	PPO Script Required HMO/POS Script Required	Pre-Auth Required	Pre-Auth Require	Pre-Auth Required	Pre-Auth Required
WELL CHOICE Provider Service: 888-476-7245 Medical Mgmt HMO 800-444-2411 Medical Mgmt. PPO 800-982-8089 Medical Mgmt. Indemnity 800-548-0120	Script Required	Script Required	Script Required	Pre-Auth Required	Pre-Auth Required	Pre-Cert Required	Pre-Cert Required	Pre-Cert Required	Pre-Cert Required

MANAGED

CARE
ORG.

MAMMO-

GRAPHY

ROUTINE

RADIOLOGY

ULTRASOUND

NON
OB/GYN

RADIATION

THERAPY

NUCLEAR

Radiology
Procedure

SCAN

PET

SCAN

MRI

MRA

AETNA

Facility ID#:

0010034

Provider Services:

800-624-0756

Member

Services:

800-323-9930

Pre-Certification

800-245-1206

NIA Radiology

1-800-648-7299

Script Required
(90 Bergen St.)

Referral
Required
If done @

150 Bergen
Street Hospital

Script Required
(90 Bergen St)

Referral Required
If done @
150 Bergen Street Hospital

Script
Required
(90 Bergen St)

Referral
Required

If done @

150 Bergen
Street Hospital

Pre-Auth Required

*See Note* listed below Regarding Changes

Pre-Auth

Required

Pre-Auth Required

Pre-Auth Required

Pre-Auth
Required

Pre-Auth

Required

Pre-Auth Required

AMERIGROUP

Facility ID #:

10076301

Provider Services:

1-800-454-3730 Ext. x1794

Member

Services

1-800-600-4441 Ext : 1788

NIA RADIOLOGY
National Imaging
Associates, Inc.
1-800-642-7565

Script
Required

Routine

No

Precertification
Required

Script
Required

Precertification
Required

Script
Required

Precertification
Required

Script
Required

Precertification
Required for
Coverage of Services Rendered In
an Inpatient
Setting

Pre-Auth
Required

Pre-Auth

Required

Pre-Auth

Required

Pre-Auth Required

United
Community
Care

(formerly)

AMERICHOICE

Facility ID 221775306

Provider Services:

888-362-3368

Member Services:

800-941-4647

Radiology
Prior Authorization
Med Solutions
888-693-3211
Fax:
888-693-3210

Script Required

Script from
PCP or OB/GYN

Yes
for Ultrasound of Breast

Script Required

Script
Required Provider
must be in Network
or Pre-Cert Required

Pre-Auth
Required

Pre-Auth Required

CIGNA HEALTHCARE

Facility ID# 221775306

Provider Services

800-244-6224

Member Services:

800-882-4462

Pre-Certification:

800-244-6224