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Health Plans Expanding Imaging Prior Notification Requirements

The ACC has been meeting with health plans and advocating for more efficient and less burdensome alternatives to existing prior notification and approval programs for cardiac imaging. Just last week, the College sent a letter to Sen. Rockefeller supporting his investigation into inappropriate pre-authorization denials for cardiac stress testing by Blue Cross Blue Shield of Delaware and MedSolutions. In addition, the College is developing an alternative plan to radiology benefit managers (RBMs) based on use of appropriate use criteria. The alternative solution would transparently reduce inappropriate imaging, while limiting hassles for doctors and reducing costs to health plans. Stay tuned for more information on these efforts.

In the meantime, several large health plans are expanding their existing prior notification and approval programs to new cardiac diagnostic modalities beginning this summer and fall. The affected modalities include echocardiography, nuclear cardiology, diagnostic cardiac catheterization, and electrophysiological device implantations (ICD and pacemakers). The requirements vary by insurer, member plan and service market and ACC members are strongly encouraged to familiarize themselves with the requirements in order to ensure proper payment. Programs that will be expanded include:

  • AETNA: As of May 15, all outpatient elective stress echocardiography and diagnostic cardiac catheterization require prior authorization.
  • Anthem BCBS (WellPoint): All outpatient elective echocardiography will require prior authorization. This will take effect Sept. 1 (CT, CO, NV, GA, NH, ME), Nov. 1 (OH, IN, KY, MI, WI) or is not yet determined (CA).
  • Highmark BCBS (PA): Starting Sept. 1, all outpatient, non-emergency imaging procedures (nuclear cardiology and stress echocardiography) will require prior authorization.
  • UnitedHealthCare (UHC): UHC will expand its prior notification program to include all outpatient, inpatient and emergent diagnostic cardiac catheterization and EP implantation procedures beginning July 1 (FL, MO, NC, OH, WI) or at a yet-to-be determined date.

The ACC will continue to work with these plans to advocate for less-burdensome alternatives. Please continue to use your ACC's imaging hassle form to report any issues with pre-authorization so the College can better advocate on your behalf.

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