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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 : Request Form and Documentation
Regardless of method of submission, the ordering physician must complete and retain the Radiology Prior Authorization Request Form with an original signature in the client’s medical record.
Providers must submit the form with the request information related to the medical necessity for the service, including all of the following:
Providers may also be asked to provide additional documentation as necessary during the authorization process.
Section 1 of the Radiology Prior Authorization Request Form must be completed, signed, and dated by the ordering physician before requesting prior authorization, regardless of the method of request for authorization.
Section 2 of the Radiology Prior Authorization Request Form must be completed, signed, and dated by the physician who performs the service prior to requesting retroactive authorization for urgent or emergent studies.
Residents, physician assistants (PAs), and nurse practitioners (NPs) may order radiological procedures; however, the ordering or referring clinician must sign the authorization form and provide the group or supervising provider’s provider identifier.
The Radiology Decision Support Tool is provided by eviCore as a resource for providers. eviCore uses the evidence-based guidelines to authorize advanced imaging services for TMHP, and these guidelines help providers determine the most appropriate treatment option for the client related to advanced imaging services. The documents include the recognized clinical guidelines for CT, CTA, MR, MRA, PET, and cardiac nuclear imaging studies.
Refer to:
Section 3, “Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility)” in Hospital Services Handbook (Vol. 2, Provider Handbooks).
Section 9, “Physician” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information on MRI and contrast material.
The Radiology Prior Auth Services page of the TMHP website at for the Radiology Decision Support Tool.

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