Paying Claims for Lesser Intensity Procedures with Radiology PA from MSI

According to the N.C. Division of Medical Assistance (DMA) Prior Approval for Imaging Policy 1K-7, claims for specific CPT codes for CT's, MRI's and MRA's should automatically pay for lesser intensity procedures when prior approval (PA) for a higher intensity code has been obtained from MedSolutions (MSI.) However, these claims are currently denying for no PA in NCTracks.

For example, approval is received for a CT without and with contrast, but the radiologist determines that the CT without contrast is sufficient. Currently, providers must call MedSolutions Intake line (1-888-693-3211), and update any authorization where the services rendered were different than authorized.

Beginning March 2, 2015, claims submitted for a CT, MRI or MRA scan with a procedure code for a lesser intensity procedure will process and pay against an approved prior approval request from MSI for a higher intensity procedure from within the same contrast family. If the billed procedure is of a greater intensity than the authorized procedure code, the claim will be denied.

This change applies to all relevant radiology claims, regardless of date of service. So, after March 2, providers will no longer need to call MedSolutions to update authorizations for a lesser intensity procedure. Radiology claims previously denied for no PA can be resubmitted. No automated reprocessing of claims is planned.