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Emergency Department (ED) High Acuity Radiology Utilization Reimbursement Policy

As part of our continued efforts to ensure evidence-based guidelines are used when making medical decisions, WellCare will be implementing a new Emergency Department High Acuity Radiology Utilization reimbursement policy.

This policy will have the following Medicare effective dates:

  • July 1, 2019 – AR, CA, CT, FL, GA, IL, LA, MS, NJ, NY, SC, TN, TX

This policy will have the following Medicaid effective dates:

  • June 1, 2019 – MO, NJ, NY
  • July 1, 2019 – FL, NE, SC

The policy was developed to address the use of high acuity radiology services in the ED resulting in patient overexposure to radiation and intravenous dye, which can lead to unintended outcomes. This policy has been created to promote the accountable use of Radiology services in Emergency Departments.

WellCare’s policy aims to ensure that provider facilities are utilizing advanced radiology procedures responsibly and only for indications when high acuity radiology procedures are deemed medically necessary. Advanced radiology procedures include, but are not limited to magnetic resonance imaging (MRI) and computed tomography (CT) services.

This policy will apply to all facilities, including freestanding facilities that submit outpatient ED claims with high acuity radiology services (CT and MRI scans) for members of the affected plans.

Upon evaluation of the submitted ED claim, if medical necessity for advanced imaging procedures cannot be determined, that radiology claim line will be denied pending chart review and the remaining adjusted amount of the claim will be paid. Facilities will have the opportunity to submit dispute and appeal requests if they believe the test was warranted in accordance with the terms of their contract as well as medically necessary.

We are here to help. If you need further information, please contact your Provider Relations representative.

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Last Updated On: 1/10/2024
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