The Company requires precertification/preapproval through Carelon Medical Benefits Management (formerly AIM Specialty Health® (AIM)) for certain high-technology radiology services for most members enrolled in its Medicare Advantage HMO and PPO products. To direct the application of these services for our members, Carelon utilizes Medicare coverage guidance (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no Medicare coverage guidance exists, Carelon utilizes their Diagnostic Imaging Utilization Management Clinical Guidelines
* or Company medical policy. For more information about the high-technology radiology services that require precertification/preapproval, refer to the current version of medical policy #MA09.002: High-Technology Radiology Services.
This service has been implemented as part of the Company's Radiology Quality Initiative (RQI) program and is intended to improve the overall clinical appropriateness of diagnostic services.
*Carelon's medical necessity guidelines are consistent with the clinical appropriateness criteria developed by the American College of Radiology (ACR). Carelon's evidence-based guidelines are supported by current medical literature and utilize resources from major medical organizations such as the American Cancer Society (ACS). Carelon is fully certified and/or accredited by the National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC). To access the complete list of Carelon Specialty Health Diagnostic Imaging Utilization Management Clinical Guidelines, click here.
