Cardiac Prior Authorization Program

The Cardiac Prior Authorization Program applies to Tufts Health Plan Commercial* products. This program applies to Massachusetts and Rhode Island Commercial plan members, as well as Tufts Health Freedom Plan members.

*Commercial products include HMO, POS, and PPO.

Providers must request prior authorization for therapeutic cardiac services by contacting National Imaging Associates (NIA) through RadMD or by phone at 866.642.9703. Using evidence-based criteria and guidelines, NIA will review coverage requests and provide authorizations for the services listed below.
Prior authorization will be required for the following nonemergent outpatient therapeutic cardiac services:
  • 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.

For a list of procedure codes subject to prior authorization by NIA, refer to the High-Tech Imaging/Cardiac Program Prior Authorization Code Matrix. To obtain and verify authorizations or access medical necessity guidelines, log in to RadMD or call directly at 866.642.9703.

This program is documented in the Cardiology Services Professional Payment Policy.

For additional information on NIA’s imaging prior authorization requirements and procedures, refer to: For more information, refer to the Cardiac Prior Authorization Program Provider Educational Webinar.
 
Note: This program does not apply to members of Tufts Medicare Complement, Commercial PPO plans with a PHCS or Cigna network, CareLinkSM, Uniformed Services Family Health Plan (USFHP), Tufts Medicare Preferred HMO, Tufts Medicare Preferred Supplement, Tufts Health Plan Senior Care Options, or Tufts Health Public Plans.
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