National Imaging Associates (NIA)
Coordinated Care has contracted with National Imaging Associates Inc. (NIA), an affiliate of Magellan Health Services, for radiology benefit management and post-service review of physical therapy, occupational therapy and speech therapy services.
The program includes management of non-emergent, high-tech, outpatient radiology services through prior authorization. This program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services.
Coordinated Care oversees the NIA program and is responsible for claims adjudication. NIA manages non-emergent outpatient imaging/radiology services through contractual relationships with free-standing facilities.
Prior authorization is required for the following outpatient radiology procedures:
- PET Scan
Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of your claim.
Go to the NIA website for more information.
Changes as of January 1, 2020
Coordinated Care does not have annual benefit limits on therapy services. However, prior authorization will be required as noted below:
|Service||Prior Auth Requirement|
|PAR Physical and Occupational Therapy||After 12 visits|
|PAR Speech Therapy||After 6 visits|
The authorization forms can be found in the Provider Resources section of this web site and should be faxed to (877) 212-6669, or submitted electronically via the secure provider portal.Participating providers may submit requests for therapy services and visit schedules starting on December 9, 2019 for dates of service on or after January 1, 2020, when those services are likely to exceed the limits noted above. Please submit the dates of service already completed with request.
Non-participating providers require authorization for all therapy services.
Neurodevelopmental related services are Exempt from these prior authorization requirements. See list of Neurodevelopmental Centers (PDF).
Please verify member benefits and eligibility by visiting our secure provider portal.
Physical, Occupational and Speech therapy services claims received on or prior to December 31, 2019 are being reviewed by NIA peer consultants to determine whether the services met/meet Coordinated Care's policy criteria for medically necessary and medically appropriate care. These determinations are based on a review of the objective, contemporaneous, clearly documented clinical records. These reviews helps to determine whether such services are medically necessary and otherwise eligible for coverage.
Claims should continue to be submitted to Coordinated Care for adjudication. All therapy claims must contain the appropriate modifier when submitted to the health plan in order to ensure appropriate adjudication. Failure to include a specialty modifier (GN, GO, GP), may result in the inability to process your claim. Medical necessity denials can be appealed through NIA. All other claims appeals are processed through Coordinated Care.
NIA may request clinical documentation on claims received up to until December 31, 2019 to support the medical necessity and appropriateness of the care. NIA will notify you if records are needed. If records are necessary, it is important you know that Coordinated Care cannot adjudicate your claims until the necessary information is received. If the documentation received fails to establish that care is/was medically necessary Coordinated Care may deny payment for services and future related therapy services thereafter. If requested records are not received, claims will be denied due to lack of information.
You will be able to upload requested records on the NIA website or through the NIA fax number, 1-800-784-6864. Medical necessity reviews are based on clinical guidelines which are available on the NIA website.
As the nation's leading specialty health care management company, NIA delivers comprehensive and innovative solutions to improve quality outcomes and optimize cost of care. If NIA therapy peer reviewers determine that the care provided fails to meet our criteria for covered therapy services, you and the member will receive notice of coverage decision.
We appreciate your participation in assuring that Coordinated Care members receive Physical, Occupational and Speech Therapy services in a quality, clinically appropriate manner.