Cardiac Prior Authorization Program
Tufts Health Plan requires Commercial (including HMO, POS, and PPO) providers to obtain prior authorization through National Imaging Associates' (NIA) for therapeutic cardiac services.
Note: This program does not apply to members of Senior Plans (including Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options [SCO]), Commercial plans using a Cigna network, CareLinkSM, Uniformed Services Family Health Plan (USFHP), or Tufts Health Public Plans.
Using evidence-based criteria and guidelines, NIA will review coverage requests and provide prior authorizations for the nonemergent, outpatient therapeutic services listed below:
- Implantable cardiac device, including defibrillator, pacemaker and CRT pacemaker
- Left heart cardiac catheterization
Note: Therapeutic cardiac services rendered in the emergency department, observation or hospital inpatient setting are not subject to prior authorization. Prior authorization is not required for members under the age of 18 on the date of service.
Prior Authorization for Outpatient Therapeutic Cardiac Services
While you may not be the provider responsible for obtaining prior authorization, as a condition of payment, you must confirm that prior authorization has been obtained. To request and verify authorizations or access medical necessity guidelines, providers may log into RadMD or call 866.642.9703.
For a list of procedure codes subject to prior authorization by NIA, refer to the High-Tech Imaging/Cardiac Program Prior Authorization Code Matrix.
Massachusetts providers may also fax the Cardiac Imaging Prior Authorization (Standard Form), with member ID and/or NIA tracking number, to NIA at 800.784.6864.