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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 : Retroactive Authorization
A request for retroactive authorization for an emergent or urgent CT, MR, PET, or cardiac nuclear imaging service must be submitted no later than 14 calendar days after the day on which the study was completed.
Retroactive authorization of urgent or emergent services is considered on an individual basis, adhering to standard clinical evidence-based guidelines. Documentation must support medical necessity for the study and must be maintained in the client’s medical record, both by the ordering physician (i.e., the physician ordering the study) and the performing facility.
Retroactive authorization for outpatient urgent services is considered when all of the following criteria are met:
The physician who renders the imaging service determines, during the provision of prior-authorized services, that additional or alternate procedures are medically indicated.
Retroactive authorization for outpatient emergent services is considered when all of the following criteria are met:
Retroactive authorization is not required when a prior-authorized CT or MR procedure is changed by the ordering physician or radiologist to a lesser procedure of the same modality (e.g., MRI with contrast is authorized and the actual procedure performed is MRI without contrast).

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