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December 2016 Texas Medicaid Provider Procedures Manual

Radiology and Laboratory Services Handbook : 3 Radiological and physiological laboratory services : 3.2 Services, Benefits, Limitations, and Prior Authorization : 3.2.6 Authorization Requirements for CT, CTA, MRI, fMRI, MRA, PET, and Cardiac Nuclear Imaging Services

3.2.6
Prior authorization is not required for emergency department services, outpatient observation services, or inpatient hospital radiology services.
Prior authorization is required for outpatient nonemergent services (i.e., those that are planned or scheduled). Prior authorization must be obtained before the service is rendered.
The following table summarizes the authorization requirements for CT, CTA, MRI, fMRI, MRA, PET, and cardiac nuclear imaging services:
 
Authorization is not required for emergency department radiology services that are rendered during an emergency department visit.
Nonemergent condition: planned or scheduled radiology service
Texas Medicaid defines a nonemergent condition as a symptom or condition that is neither acute nor severe and can be diagnosed and treated immediately, or that allows adequate time to schedule an office visit for a history, physical, or diagnostic studies prior to diagnosis and treatment.
Prior authorization is required for outpatient nonemergent (i.e., those studies that are planned or scheduled) CT, CTA, MRI, fMRI, MRA, PET scan, and cardiac nuclear imaging services.
Important:
The authorization number must be on the claim when it is submitted to TMHP for reimbursement. Only one authorization is allowed per claim. For the most accurate and efficient claims processing, TMHP recommends that the procedure code that is submitted on the claim match the procedure code that is authorized. Providers are encouraged to contact TMHP and update the prior authorization if the ordering physician or radiologist changes the actual procedure that is performed. Providers have 14 calendar days after the day on which the study was completed to update the prior authorization.
Additional or alternate studies identified and ordered by the radiologist at the time of a prior-authorized study meet the definition of urgent condition and require retroactive authorization.
Retroactive authorization is required for unplanned radiology procedures performed during other planned or scheduled outpatient visits or procedures.
Texas Medicaid defines an urgent condition as a symptom or condition that is not an emergency, but requires further diagnostic work-up or treatment within 24 hours to avoid a subsequent emergent situation.
Note:
Additional or alternate studies identified and ordered by the radiologist at the time of a prior-authorized study meet the definition of urgent condition and require retroactive authorization.
Retroactive authorization is required for unplanned radiology procedures performed during other planned or scheduled outpatient visits or procedures.
Texas Medicaid defines an emergent condition as a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, or symptoms of substance abuse) such that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in at least one of the following:
Placing the recipient’s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy
The physician must determine that a medical emergency, which imminently threatens life or limb exists and that the medical emergency requires advanced diagnostic imaging.
Prior authorization of nonemergent services is considered on an individual basis, adhering to standard clinical evidence-based guidelines. Documentation must support medical necessity for the service and must be maintained in the client’s medical record, both by the ordering physician (i.e., the physician who orders the study) and the performing facility.
Nationally-accepted guidelines and radiology protocols based on medical literature are used in the authorization processes for urgent, emergent, and nonemergent services. These include, but are not limited to:
Refer to:
Subsection 3.2.2.3, “Authorization Requirements and Flexibility” in this handbook for information about authorization flexibility for CT, CTA, MRI, fMRI, and MRA procedures.

Texas Medicaid & Healthcare Partnership
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